Legal methadone is the little known backbone of Vancouver's harm reduction approach to drug addiction. It's also a tidy business for pharmacies that routinely break their industry's own regulations.
On the sidewalk outside Knowltons Drugs Pharmacy at Carrall and Hastings in the Downtown Eastside, Philip Ahl, a 28-year-old crack addict, quickly scans the crowd of drug users, dealers and prostitutes before gazing back through the pharmacy's large front window. Two employees in white lab coats work busily behind a wall of glass, which protects large supplies of methadone and other drugs coveted by drug users.
Pale, skinny and covered in tattoos, Ahl's boyish looks and bright blue eyes belie his arduous existence on the streets of Vancouver. A former heroin addict, Ahl has used methadone "on and off" for five years and feels trapped in a cycle of dependence. He's angry with the government bureaucracy in charge of his daily fix.
"They let it become a crutch, so people are lifers. Methadone should be used temporarily as an augmentation to therapy, so you can get used to being a productive member of society again."
B.C.'s Methadone Maintenance Program forms the backbone of Vancouver's harm reduction approach to drug abuse, disease and crime in the Downtown Eastside. Of Vancouver's 164 pharmacies, 79 sell methadone and 13 of the 19 pharmacies in the Downtown Eastside sell the drug to recovering heroin addicts, while PharmaCare--a branch of the provincial Ministry of Health--foots the bill.
Between April 2007 and March of this year, PharmaCare bought methadone for 8,400 people in B.C. An untold number of methadone users are outside the PharmaCare program.
While the Insite supervised injection site gets all the press, the methadone program operates largely under the radar and out of public view. But no harm reduction program is more ubiquitous in the drug culture of the Downtown Eastside. And while methadone is legal, critics and users paint a picture of a program that breaks its own rules while doing little to lift addicts out of dependency.
Methadone is a synthetic opioid developed in 1937 in Nazi Germany, where government officials feared a raw opium embargo would limit the supply of morphine and other opiates for frontline soldiers. Although tested by the military in 1939, Nazi officials decided against widespread use because of methadone's addictive qualities.
In North America, it was first used to treat heroin addicts in the mid-1960s in New York City and was widely used in Vancouver later that decade. Its long-lasting effects, which are similar to morphine and heroin, help stabilize addicts and prevent heroin withdrawal symptoms. Methadone also partially blocks the "rush" associated with heroin use.
Although the methadone program is administered by the B.C. College of Physicians and Surgeons--thanks to a federal exemption that allows doctors to prescribe the drug--the B.C. College of Pharmacists oversees the program and ensures that participating pharmacies act in accordance with program regulations.
Aside from regulating methadone distribution, the College of Pharmacists proactively recruits pharmacies into the methadone industry. There is no additional licensing or registration required, and pharmacies are free to purchase methadone from wholesalers.
The college's website offers a step-by-step application guide to the program and a list of answers aimed at placating pharmacist concerns.
From April 2007 to this past March, the province--through PharmaCare--paid $27 million in methadone reimbursements to private pharmacies in B.C.
Inside Knowltons Pharmacy, Shane Sinclair shuffles his weather-beaten running shoes on the shiny linoleum floor and furiously scratches the back of his neck. Sinclair, a 40-year-old unemployed construction worker and welfare recipient, has been on methadone for two years after several years of heroin addiction. He smokes crack, is homeless and sleeps under a tarp in a park near Shaw Tower.
Knowltons is a regular hangout for Sinclair. In exchange for a few dollars, he sweeps the floor inside the pharmacy where he gets his daily dose of grape-flavoured methadone. A typical methadone user, Sinclair gets one 70 milligram dose per day.
Typically, powdered methadone is mixed with water and a drink flavouring--usually orange or grape--at a ratio of one milligram of methadone to one millilitre of liquid. Individual doses are measured in a flask and poured into disposable Styrofoam or Dixie cups. In accordance with regulations, pharmacists must watch users drink the methadone in the pharmacy.
However, on the streets of the Downtown Eastside, the shouts of "methadone" mix with "rock" and "pot" as street dealers ply their trade. Despite the rules, somehow methadone makes its way out pharmacy front doors and into the black market.
Sinclair says many users sell their "juice" on the street to supplement their welfare cheques. The black market rate for methadone is 10 cents per mg, so a typical 70 mg dose fetches $7 on the street.
Under the PharmaCare agreement, pharmacies are not allowed to charge methadone users any amount above the original acquisition price, which is two cents per millilitre or lower. Subsequently, most of the $27 million paid by PharmaCare to methadone pharmacies was for so-called "related pharmacy fees" including a maximum "dispensing fee" of $8.60 and an "interaction fee" of $7.70. Both fees are set by PharmaCare.
In other words, pharmacies heavily involved in the methadone program--mainly pharmacies in the Downtown Eastside--make their money from the distribution of the drug, not the drug itself.
With so much government money up for grabs, competition among methadone pharmacies--particularly in the Downtown Eastside--is fierce. Pharmacies woo users with free coffee and cookies--a violation of the College of Pharmacists' "no inducements" policy--and in another regulation violation, openly advertise methadone services using makeshift posters on pharmacy windows.
While many citizens may shrug their shoulders at coffee and cookies for destitute addicts, taxpayer-funded kickbacks are another animal entirely. And word on the street is that it happens all the time.
Dave Dickson, a retired Vancouver Police Department officer who spent more than 20 years as a Downtown Eastside street cop, says it's common knowledge among area residents that certain methadone clinics pay kickbacks to customers for their prescriptions. "It's the taxpayer's money, so I'm sure a lot of people would say 'wait a second,'" Dickson says.
The Courier interviewed several Downtown Eastside methadone users for this story and discovered that, among area pharmacies, the going rate for kickbacks to users for a weekly prescription, which includes daily doses, is $10.
Both Philip Ahl and Shane Sinclair--two methadone users who agreed to go on record--agreed with this number but refused to identify offending pharmacies by name.
The Courier contacted the College of Pharmacists about alleged kickbacks in the methadone program. After three interviews with three different spokespeople, the college admitted there might be a problem.
"We have received complaints and we are doing some investigation now," says Suzanne Solven, deputy registrar at the college, which is headquartered in an office at Eighth Avenue and Burrard Street.
Solven would not reveal who complained or how many complaints the college received, but said alleged kickbacks may be the result of a competitive methadone market.
"There's only so many methadone patients and there's only so much business so it's probably a business incentive, just as you see regular pharmacies doing pharmacy loyalty points and those kinds of things," said Solven.
She refused to speculate on possible punishments for pharmacies found guilty of paying cash to methadone users, although she noted the alleged kickbacks violate the PharmaCare agreement but do not constitute a crime.
And what about free coffee and methadone advertising? In two square blocks in the Downtown Eastside, four out of five pharmacies advertise methadone and offer free coffee for methadone patients.
Solven would not say whether disciplinary action was pending but described the disciplinary process. "It could just be a matter of sending a letter to the pharmacy manager saying remove the sign or the newspaper ad or the Internet ad or whatever," says Solven. "Then we would follow up with a further inspection to make sure they've actually done that."
According to Solven, chronic offenders could lose certain drug distribution rights or be shut down. However, she could not cite one instance in the past where pharmacies were disciplined due to methadone violations.
In May 2001 Surrey city council, fed up with loitering outside methadone pharmacies, introduced rules prohibiting pharmacists from offering "a cash incentive or other inducements to attract clients to the store for a methadone prescription." Vancouver has no such bylaw.
The Ministry of Health would not comment on alleged kickback allegations involving government-funded methadone prescriptions.
Most Downtown Eastside pharmacies refused to cooperate with the Courier for this story, including Knowltons Pharmacy, where many methadone users congregate outside on the sidewalk.
However, a Gastown Pharmacy employee ( who wished to remain anonymous ) admitted he gives coffee to methadone users. He said he does not offer cash in return for methadone prescriptions, but said he's heard "rumours" about other Downtown Eastside pharmacies.
While it may be convenient for Gastown Pharmacy to implicate its competition in a kickback scheme, several methadone users said Gastown Pharmacy was not popular among methadone users because the pharmacy did not hand out cash kickbacks.
Despite allegations of kickbacks and rule-breaking, the medical community has steadfastly endorsed the methadone program since its inception because of its ability to curb intravenous heroin use and the transmission of HIV and hepatitis.
Virtually any heroin user can get on methadone. The process is simple. A drug user visits a medical doctor, who performs a checkup that includes urinalysis and a blood test. If the patient is deemed eligible, he is given a prescription for methadone and is free to visit the methadone pharmacy of his choice.
While the degree of consultation varies, doctors stay involved in the process and sometimes administer regular blood tests. However, detection of other illicit drugs such as cocaine does not disqualify patients from the program.
Furthermore, the program does not include mandatory treatment or counselling--although prescribing physicians may recommend such measures--and there is no limit to the amount of time a patient is on the drug.
The lack of accountability leaves addicts like Philip Ahl scratching their heads. "It's unmonitored," says Ahl, from the sidewalk outside Knowltons Pharmacy.
Ahl echoes the sentiments of many Downtown Eastside methadone users who say methadone is just another drug among the cornucopia of illegal drugs--most notably crack cocaine--available on Vancouver streets.
"Methadone perpetuates my drug use and exploits it," says Ahl. "Because I don't have to worry about that fix anymore. So you go looking for the cheapest most accessible high--crack. Methadone is a free pass for feeling good."
While methadone is not the sole undoing of Ahl's life, his indictment of the methadone program is notable considering his daily reliance on the drug. A carpenter by trade, Ahl draws welfare and lives in the Stanley/New Fountain Hotel in Blood Alley. He hasn't worked since 2006. During his five years of "on-and-off" methadone use, Ahl says the hardest thing about the program is getting out. "I had no difficulty getting on it, but it was getting off where I had difficulty. It's easy to take methadone and keep living the life you're living. It's harder to take methadone and change."
Ahl's made two attempts at rehabilitation in the past four years, most recently last winter when he spent one month at the Kinghaven Treatment Centre in Abbotsford. He couldn't hack it, and wound up back in the Downtown Eastside, drawn by crack cocaine and government-funded methadone.
Shane Sinclair also hopes to one day wean himself off methadone, but for now he's happy.
Like Ahl, Sinclair says many drug users enter the methadone program and concentrate their illegal drug use on crack cocaine. He claims the quality of heroin in the Downtown Eastside, which he says has dropped considerably over the past two years, is pushing more people into the program.
"Heroin around here is crap," he says to the nodding acquiescence of two methadone users standing in a nearby line inside Knowltons.
"In 2005, 2006, it was actually pretty good," he says, adding that the nature of methadone, and its slow grip on the addict, makes it more addictive than heroin. "There's a high for the first couple days, then you don't really feel high any more. But coming off it is worse than a heroin withdrawal. It's like breathing. When you don't have it you panic and can't handle it."
The guidelines for the methadone program, available on the College of Pharmacist's website, perhaps provide cold comfort for addicts like Sinclair and Ahl.
"Eventual withdrawal from methadone," reads the website, "is not necessarily the goal of the program."
BY VANCOUVER COURIER
SEPTEMBER 5, 2008