Health

TOO MANY DEATHS

As Ontario’s methadone program for drug addicts expands, so do fatalities

DANYLO HAWALESHKA February 25 2002
Health

TOO MANY DEATHS

As Ontario’s methadone program for drug addicts expands, so do fatalities

DANYLO HAWALESHKA February 25 2002

TOO MANY DEATHS

Health

As Ontario’s methadone program for drug addicts expands, so do fatalities

DANYLO HAWALESHKA

The detective who investigated Jessica Weber's death is reluctant to say much about how she died. An Ontario court will decide that after a preliminary hearing expected this spring. Jessica's parents, grieving the loss of their teenage daughter, would rather not talk either. Losing their 15-year-old girl makes so little sense.

Last July, Jessica was babysitting not far from her home in Kitchener, a little over an hour’s drive west of Toronto. Several friends dropped by. Police believe one of the visitors spiked Jessica’s drink with methadone, a powerful synthetic opiate normally used to wean addicts off heroin. She allegedly drank it without knowing, then went to a relative’s home where ambulance attendants found her unconscious and not breathing. Police charged Michael McAllister, 19, with manslaughter, trafficking and obstruction of justice. The case troubles Dr. James Cairns, deputy chief coroner for Ontario, who sees signs that growing numbers of youths are getting mixed up with methadone. Jessica’s death,

says Cairns, “is really raising alarm bells.”

Hers and many others. Cairns is investigating 233 deaths in Ontario dating back to 1998 in which toxicologists detected methadone in the deceased’s body. The province and its doctors are coming to terms with a tragic snafu. When prescribed with care, and coupled with counselling, methadone can be an extremely effective treatment for heroin addicts. It helps curb the craving and frees addicts from the pressure to beg, borrow and steal the hundreds of dollars a day required to feed a devastating habit. Methadone also minimizes the transmission of AIDS and hepatitis by reducing the possibility that addicts will use dirty needles to inject it. But when the controls are lax, as seems to be the case with some of the methadone given to the more than 6,500 opiate abusers in Ontario’s program, the drug can become a killer.

Quebec and British Columbia, the two other provinces with significant populations of heroin addicts, have similar problems but seem to be doing a better job of handling methadone. In Quebec, 110

doctors treat roughly 1,750 patients. In 2000, the most recent year for which figures are available, Quebec had a record high of 10 deaths in which methadone was found in the deceased’s body. On a proportional basis, however, Ontario’s death rate that year was almost 50 per cent higher.

British Columbia, home of Vancouver’s infamous Downtown Eastside, has long had the largest population of methadone users in Canada. More than 8,000 patients receive the treatment in B.C., yet deaths directly attributable to methadone have been decreasing, says Peter Hickey, executive director at the College of Physicians & Surgeons of British Columbia. Comparisons, however, are hampered by a lack of new numbers. From 1997 to 1999, deaths in which methadone was detected ranged from 30 to 40—at a time when the number of patients increased by 75 per cent. Unlike Ontario, B.C. puts a 400-mg cap on the amount of methadone patients are allowed to take home at a time. Any doctor who wants to give a patient more must ask the B.C. college for permission. That is

to double-check that the increase is justified, says Hickey, “but also to ensure that the public is not put at risk by an increased amount of methadone out on the street.”

And that appears to be the problem in Ontario—too much methadone on the street. The amount being doled out has increased sharply, as has the number of physicians authorized to prescribe it to opiate addicts. Ontario doctors, meanwhile, allow a relatively large percentage of patients to take some days’ worth of methadone doses home—leaving the possibility that some of it will be sold on the black market. While methadone isn’t a drug of choice, some addicts seek it out to tide them over until they can score their heroin, or perhaps painkilling Dilaudid. Rather than answer doctors’ questions and submit urine samples, they will buy from a dealer.

Methadone is prescribed in a mixture with orange juice to mask its bitter taste and prevent it from being injected. Ontario guidelines advise doctors to have addicts drink their dose in the presence of the prescribing pharmacist for at least two months to ensure they are taking it properly. As patients become more stable, they can earn the privilege of taking home their doses—typically referred to as “carries.” Ontario doctors, however, have been starting some carries well before the two months are up and, overall, making them available to about 70 per cent of addict patients. (In B.C., by contrast, just 22 per cent of addicts get carries.)

It’s not that the methadone program is without merit. Dr. Jeff Daher, medical director for the Ontario Addiction Treatment Centres, with six clinics in southern Ontario, points to its success in keeping people healthy and out of jail. “The untreated heroin addict,” Daher notes, “costs society roughly $50,000 per year, but the addict in a methadone clinic costs about $5,000 per year.” Daher and a staff of 16 doctors as well as therapists treat more than 1,000 opiate addicts. “The risk, of course, is that the dose gets diverted onto the street,” says Daher. “I’m certainly not saying nothing gets out of our clinics.” But that risk, he says, must be weighed against clear benefits.

Responsibility for overseeing the drug program falls to Dr. Graeme Cunningham, who chairs the methadone governance committee for the College of Physicians and Surgeons of Ontario. Doctors

who prescribe methadone for opiate addiction, he says, are held accountable to the college’s strict guidelines. That’s not to say they play no part in the problem. But Cunningham suggests another way that methadone may be leaking into the community—from Ontario’s 153 physicians prescribing methadone “with no accountability” for chronic-pain relief. They operate without specific guidelines, he says, and they aren’t required to include their patients’ names in a central registry like the one used to track opiate-abusing patients. “I have no doubt,” says Cunningham, “that the more prescribers of methadone you have, the more methadone is going to turn up in the community.”

Still, several recovering opiate users told Macleans that many Ontario doctors treating addictions are too eager to prescribe carries.

Mark Bilodeau, a Kitchener-based tattoo artist who, at 40, has been a heroin addict in and out of jail for 20 years, says it’s never been easier to get methadone on the street. He blames doctors in a hurry. “They’re ready to put you on it just like that,” Bilodeau says with a snap of his fingers.

Mark Leitch’s story is a case in point. Three years ago, after years of heroin abuse and trafficking drugs, Leitch found himself at an Ontario clinic where he could get as much methadone as he liked. All he had to do, he says, was claim his dose wasn’t high enough to curb his heroin cravings and his doctor would scribble a new prescription. “Everybody in the program except one trafficked in their methadone,” he says. Leitch, a slim 30-year-old with brown hair pulled back in a ponytail, now attends a strict methadone program in Kitchener that tolerates no illicit drug use. He occasionally runs into his old acquaintances and they’re still stoned, he says, and still pushing methadone.

Leitchs doctor, Ralph Stemeroff, parts from some of his methadone-prescribing colleagues in insisting his patients give up other drugs. Only after three months of responsible behaviour does he consider them for limited carries. “I don’t give carries unless they’re clean,” says Stemeroff. “That’s for the safety of the patients, as well as the people around them.”

Typically, people who take too much methadone fall asleep. At a party, you might think the person had too much to drink and passed out. You’d be dead wrong. Some will twitch or vomit. The breathing slows, the blood pressure drops, the person lapses into a coma and the heart stops.

A therapeutic dose for one person can easily kill another. Methadone users must build tolerance by starting with small amounts. To the uninitiated, a low dose can bring on a gradual feeling of euphoria. Methadone is particularly dangerous when mixed with other respiratory suppressants—alcohol, cocaine, Valium, codeine—when passed off as another drug, or when slipped into someone’s drink, as is alleged to have happened in the Weber case.

Methadone programs were scarce in the early 1990s, when Canada lagged behind other western nations. Addicts waited many weeks for help. In 1995, the federal government downloaded responsibility for methadone treatment to the provinces. Ontario and B.C. responded quickly, giving physicians greater latitude in determining treatment and take-home privileges. In Ontario, unfortunately, the bodies began piling up. In 1996, nine people died with methadone in their systems. By the next year it was 47, then 64 the year after that. Meanwhile, the number of doctors prescribing the drug has risen from 41 in 1996 to more than 200 now, and the number of patients skyrocketed almost sevenfold, from 975 to 6,571. Cairns launched his first investigation in 1998.

The deputy chief coroner determined that, of the nine who died in 1996, methadone directly killed two and contributed to the death of four. The methadone detected in the bodies of the other three, he found, played no part in their deaths. In 1997, methadone killed or helped kill 36 of the 47. Cairns is now well into a second investigation, reviewing deaths from 1998 to 2001. He expects to report in April.

The results of his first study were troubling enough. Almost a third of those who

TROUBLING NUMBERS

Deaths in Ontario in which methadone was detected in the deceased:

•to Nov. 2001

As the number of physicians treating patients with methadone in Ontario grew, the caseloads skyrocketed:

1996 1999 2002

Doctors 41 120 221

Patients 975 5,000+ 6,571

Sources: Office of the Chief Coroner for Ontario; College of Physicians and Surgeons of Ontario; Centre for Addiction and Mental Health

Health

died were enrolled in methadone-treatment programs, and all but a few of them died within a week of being put on the drug. Conclusion: Ontario doctors were killing their patients by upping doses too quickly. “We’ve always been told start low,” says Cairns. “There was a warning— don’t go up too soon, but it hadn’t been driven home.”

Equally troubling were the two-thirds who were not in methadone programs. Most of them were not known to be heroin addicts—they were first-time users, casual experimenters. Methadone, Cairns concluded, had become a drug of abuse. He received numerous anonymous tips that addicts were diverting their methadone. “There certainly seemed to be information out there that some people were getting carries and selling them,” he says. But he couldn’t prove it.

Five months later, in the summer of 1999, the Ontario college created its methadone governance committee and appointed Cunningham, director of the addiction division at Homewood Health Centre Inc. in Guelph, as its chairman. The college adopted a “go low, go slow” approach to dosing.

That year 65 more people died with methadone in their systems. In 2000, the toll dipped to 53. Last year it was 51 as of November, the latest month on record. Until Cairns reports, it will remain unclear how many of those deaths are direcdy or indirecdy attributable to methadone. The college audits physicians to ensure they comply with the guidelines, but only 105 out of 221 have so far had their records checked.

Clearly, methadone-related deaths have risen in Ontario since 1996. But has the methadone program also lowered the number of deaths from heroin overdose? Possibly. The most recent numbers available indicate a downward trend—80 deaths from heroin in 1996, then 129 in ’97, followed by a drop to 91 in ’98 and to 57 in ’99. But there is no evidence to relate that trend directly to the methadone program.

The college also does not track how many addicts in Ontario’s methadone programs are now functioning well enough to hold jobs. But to Cunningham, seeking that kind of evidence is like asking doctors to justify using insulin for diabetics—everybody knows it works.

“Methadone is the most scientifically investigated drug,” he says. “We know that heroin addicts who go on methadone return to the mainstream of living.”

Some get there despite the treatment they encounter in clinics. Today, Doris (not her real name) is a 28-year-old nursing student with a promising future. Fourteen years ago she started taking Tylenol 3s, which contain codeine, for chronic abdominal pain. As Doris built a tolerance to the painkiller, she moved on to Percocet, Supeudol and eventually Dilaudid, which she’d crush and liquefy to inject as a clear cocktail. “I was so good at telling the doctor that I wasn’t addicted,” she says, “that no questions were asked.” About 18 months ago, Doris checked into a detox clinic, where she says her physician treated her with indifference. “I got no respect from the doctors in Toronto,” she says. “My mother was right—they treat you like an addict, you’re just a piece of shit. How are you supposed to get better like that?” At first she tried going cold turkey, declining any methadone. She became violently ill and says her doctor wouldn’t see her daily as promised. After six weeks, she moved home with a referral to a nearby clinic where she did use methadone under strict controls before weaning herself off that, too.

As good as it can be, methadone has a way of falling into the wrong hands. Ontario’s guidelines call on physicians to advise patients to keep take-home doses in a locked container if other people, especially children, could have access. Patients keep their juice mixtures refrigerated. In 1998,

a six-year-old boy in Toronto, thinking his father’s methadone was orange juice, drank some and died.

That scenario frightens Jennifer DeWaard. At 19, she began injecting Dilaudid, in part to ease pain caused by irritable bowel syndrome. Now 25 and working as a courier-service dispatcher, she has been clean for almost two years under the care of Stemeroff, who requires that his patients lock up their carries. Another clinic DeWaard had attended had no such constraint. “It was scary,” she says. “A lot of people had children.”

It’s not just kids who get into it. Joseph MacKenzie, 22, a labourer in Kitchener, died after drinking methadone prescribed to a woman with an opiate addiction. It was in the refrigerator, unlocked, and police think MacKenzie, who was visiting the apartment, drank it after the woman went to bed. Two weeks earlier, MacKenzie had visited his mother, Reta Sandy, at her home near Wiarton, 165 km north of Kitchener. Her voice trembling, Sandy says she asked him to stay to help build an addition to her house. “He said he had some stuff he had to get done and that he would be back,” she says. “I didn’t know he’d be coming back in a pine box.”

Sandy says she often thinks of Jessica Weber, who died in the same city less than two months later. “Her parents don’t have a grandchild to hug,” she says. “They’ll never see her get married, graduate or have her first child.” She wonders why methadone is not more strictly controlled. “How many more will have to die?” asks Sandy. It’s a fair question. EH]