A recent study found the new formulation of methadone, called Methadose, and the regime used to administer it are leading to withdrawal symptoms and heroin relapse among patients.The study, published in the Social Science and Medicine journal, found that the vast majority of study participants experienced heightened withdrawal symptoms about 14 to 16 hours after ingesting the new methadone. The old formulation had previously lasted at least 24 hours, until patients got their next daily dose.

These findings confirm a story I broke in Megaphone last year, citing the experiences of users, frontline workers and harm reduction advocates after provincial authorities forced more than 15,000 patients onto the new methadone and made substantial changes to the way it’s administered. Working with the BC Association of People on Methadone (BCAPOM), I witnessed the negative impacts of the new formulation from the start.

Methadone is a medication prescribed to treat withdrawal and the various effects of addiction to heroin of other opiates—not lead people back to their use.

“Within three days I was back to using heroin”

Allan Fowler started feeling bad just after he was switched to Methadose. He’d been on the old methadone for five years and had gotten clean. But “within three days I was back to using heroin, picking up Dillies [Dilaudid], morphine,” he said. Patients could count on the old methadone to work steadily until their next daily dose. But for Fowler, Methadose wasn’t lasting a full day. “Within 16 hours, I was getting really sick,” he said. “Then, 100 per cent relapse.”

Ryan McNeil heard the same thing from most of the 34 participants in his recent study of changes to Methadone Maintenance Treatment (MMT) in B.C.

McNeil is a postdoctoral research fellow with the Urban Health Research Initiative of the BC Centre for Excellence in HIV/AIDS. “The vast majority of people [we] spoke to talked about experiencing heightened withdrawal symptoms,” he says, “usually beginning within 14 to 16 hours after ingesting [new] methadone, as opposed to the day that it would have previously carried them.”

For 75 per cent of McNeil’s study participants, this caused problems.They “missed doses,” he says, and experienced “withdrawal symptoms that, in turn, led to increased injection opiate use, as well as the consumption of diverted [black market] methadone.”

Chereece Keewatin participated in McNeil’s study. “I’m happy there’s people out there that care enough to listen to us, to believe us,” she says of the study. As part of the BCAPOM, Keewatin became familiar with official indifference.

After 11 years on methadone, she says Methadose failed her. “I never used heroin for years and years on the other stuff [the old methadone formulation].”

But after the switch to Methadose came withdrawal and relapse: “I was really sad to go back to that stuff [heroin]. I thought [heroin addiction] was over.”

Keewatin is frustrated. “Why would they change something that is already working?” she says of officials in charge of MMT. “They’re not sick. They’re not the ones who are taking it.”

Hacking at liquid handcuffs

Patients have always been policed by the methadone system in B.C.

McNeil’s study found that the increasingly restrictive methadone regime further marginalizes an already vulnerable group. According to his report, it creates obstacles for patients with “insufficient resources (e.g., lack of transportation) or disruptions due to drug criminalization (e.g., arrest, detention) or housing instability (e.g., homelessness, eviction).”

One of those obstacles is that now people have to come to the pharmacy to access methadone. This policy change came in at the same time as the new methadone was introduced. Methadone deliveries enabled treatment for patients who couldn’t afford bus fare to and from a pharmacy every day.

Not being able to get to the pharmacy disrupts this treatment, and that can be devastating. One participant described the experience of getting sick after missing a dose as “heroin withdrawal times 10.” Having to drink the methadone every day under the watchful eye of a pharmacist, having to consent to regular urine testing, and frequent doctor visits is like a pair of “liquid handcuffs,” many patients say.

McNeil’s study suggests that the strict regime “operates as a form of biopower, regulating the bodies and lives of people on methadone.”

McNeil and his co-investigators also found that doctors were unlikely to adjust doses to compensate for withdrawal symptoms, leaving patients to devise their own solutions. Some bought additional methadone illegally on the street to“top up.” Others used heroin or various opiates to treat withdrawal symptoms.

Not just guinea pigs

For methadone patients, big changes can lead to big problems. This phenomenon has been documented for decades. In a 1992 study, researchers Steels, Hamilton, and McLean found “a decline in social stability and an increased use of non-prescribed drugs in some patients” when their methadone formulation was changed. Gourevitch and his colleagues noted the vulnerability of “those at risk for intolerance to the change” in a 1991 study.

These kinds of findings should have alerted officials to the fact that methadone patients are very sensitive to big changes. Regardless, B.C. authorities went ahead with what the McNeil study called a “natural experiment.”

Drug users on Vancouver’s Downtown Eastside are one of the most studied populations anywhere.

But often participants never know what happens to their data. The Vancouver Area Network of Drug Users’ (VANDU) volunteer coordinator and community organizer, Aiyanas Ormond, explained what VANDU asks before participating in any study: “Is this research going to actually support empowerment and social justice for people? Is it going to leave our movement stronger after the researcher is gone?” For his methadone study McNeil partnered with VANDU, giving the group a voice in the research process.

Cascading harms

When methadone treatment fails, it can mean a return to heroin, crime and the sex trade—what the McNeil study calls “cascading harms of MMT disruption.”

The study concludes that the MMT regime is too focused on “reforming ‘irresponsible drug users’ ...[and on the] ‘discipline’ of people on methadone.” In our conversation, McNeil kept strictly to his data. But, he reflected, “These changes have had such a devastating impact on people enrolled in methadone. It’s really sad.”

Last August, BCAPOM wrote to Terry Lake, B.C.’s Minister of Health, about the problems caused by the switch to Methadose. Minister Lake told a press conference that he would look into the situation.

An emailed statement from the Ministry of Health dismisses the McNeil study, saying it uses a small sample size. I asked about the impacts from Methadose. They wrote: “we have no scientific evidence of this effect.. we also have had no new complaints.” The ministry encourages patients to talk totheir doctors if they are having problems.

McNeil disputes the provincial government’s assertion of lack of evidence. “Formulation changes should be undertaken with awareness that the phenomenon of ‘change intolerance’ is well established in the academic literature,” he says.

McNeil points out that the study had reached a point of “data saturation” at 34 interviews. That is, a point in qualitative research where no new information is being revealed. Regardless, research continues: “We are currently analyzing data from our larger data sets to further understand these dynamics at the population-level,” McNeil says.

Study participant Chereece Keewatin was on the BCAPOM board when the group sent that letter to Minister Lake.

After being switched to Methadose, she started using heroin. Today, she says, “heroin is a totally different game. You gotta scrabble every day to pay for it.”

That scrabbling takes the time, energy and spirit that Keewatin would have spent on advocacy. She’s not optimistic the McNeil study will change things.

Doctors, patients, activists and researchers are all starting to point to the same set of negative impacts: last year’s radical changes to MMT are leading to serious problems among patients. It’s time for those in charge to start listening.