Comments on London's Proposed Methadone Facility Bylaw

How will I keep my job - if you have to close by six pm?

Why do they think it's people from here - who leave needles in downtown streets? Don't they know that this place got me off the street?

They take pictures of three people standing out front of the clinic. What about all the rest of us - who are back in school, at work or looking after our kids?

These are just some of the questions asked this past week - at 528 Dundas Street in London - in response to recent news articles about what started out as a bylaw to limit the location of new methadone facilities - but that seems to have expanded into a set of program regulations for addiction treatment.

Aside from the many spurious arguments used to justify the proposal - the writers of this document seem oblivious to the single issue that is at the root of what concerns do exist in the vicinity of 528 - and elsewhere in this city.

Why is it that twenty years ago there were only a handful of London residents in methadone treatment - while today there are at least twenty-five hundred? Why is it that even with the portrayal of this facility as a mismanaged house of horrors - ten London residents come to our door each week seeking help? And why is it that after ten years of offloading clients to other facilities, streamlining program processes, increasing clinic hours and staffing - we can barely keep up with demand - and are one of the busiest clinical facilities operating in this city?

The answer to all of these questions is the same - and that seems to be the best kept non-secret in London, Ontario.

Eighty percent of all clients seen at 528 Dundas Street in the last decade have come because they are in trouble with oxycodone based prescription painkiller drugs. They see that their use of these drugs - known as Oxys, Eighties, Forties or Percs - is destroying their health, family and life. They have tried over and again in many ways - but either cannot stop taking these drugs - or else cannot stay stopped for long.

Many of the clients seen at 528 were first prescribed these drugs by their own doctor - developing severe and lasting complications of their treatment. Many other young, naive, reckless or otherwise vulnerable clients began to take these drugs for reasons of recreation or self treatment - a trend fueled by changes in physician prescribing habits and that have resulted in the commonplace availability of these drugs in our homes, schools and on the streets.

The prescription of oxycodone based painkiller drugs in Ontario increased by eight hundred and fifty percent between the years 1991 and 2006. Its rate of prescription continues to climb at a double digit rate to this day. It is prescribed for pain relief - but the issues pertinent to this writing have little to do with pain relief - and nothing to do with the many people who are able to take them with benefit and without complications.

The issues of concern have to do with the many other effects and complications of these drugs. Opiate drugs are the most powerful 'feel good' drugs known to mankind - with a long history of foolish recreational and unhealthy habits of use. When some brains interact with these drugs - the chemical changes of compulsive desire are initiated - the starting point of the condition that we call addiction.

Taken over time, these drugs can also induce other changes in the brain - requiring increases in dosage - at first to maintain effect and later - just to feel half normal for a while. After these changes have set in - distressing physical symptoms called withdrawal occur whenever the drug is not consumed.

It is these changes - increasing tolerance - repeated efforts to discontinue use with escalating fear of withdrawal symptoms - that can drive some people to desperate actions in order to obtain the drug. These are the same problems that fortunately encourage others - to ask for help at a treatment centre.

I do not know why some people react to these drugs in these ways - while many others do not. I also do not know why most given a stimulant drug will be energized - while some children with a slightly different brain structure will experience an entirely opposite and calming effect - with exactly the same drug.

I do know that by the time these drug induced changes begin within the brains of some people - the stage is set for an escalating sickness that can destroy health, family and life. I also know that the brain changes that occur in some people who take these drugs are astonishingly difficult to reverse - and can lead to years of sickness, intensive treatment - and unimaginable personal struggle.

The issues are not just to do with oxycodone. This drug - invented in 1917 but not marketed until the 1980's - is only the most recent experiment. Before oxycodone there was opium, heroin and morphine. Now there is fentanyl - an even more addictive and dangerous drug increasingly available on the street. Otherwise all of these drugs are more similar than different.

There will always be a new and more potent of these drugs brought to market - for the simple reason that these drugs do not just respond to need. They create need. They do not just treat sickness. They also create deep sickness in some people - and these people will often struggle with these drugs and / or require ongoing involvement in a treatment program for years of their life.

Most of the people who I have seen at 528 do not want to continue to use these drugs. They have all tried to stop many times and in many ways. But the changes that have occurred in their brain torture them with physical pain and distress when they try to do so. The withdrawal symptoms - and fear of withdrawal seem to worsen with each episode of recurrence.

Both substance addiction and physical dependency are initiated by an interaction between a vulnerable brain and a consumed substance. The brain then starts to send out messages to take more drug. These problems can take hold before they are even noticed - and one's freedom to assert healthy choice is affected, gradually eroded and sometimes worn away entirely.

It is these issues - addiction and physical dependence - that bind some people to an opiate drug by gradually overwhelming their ability to walk away. And these issues have been clearly recognized for centuries.

Have a look at the poster to the right - from a time one hundred and twenty years ago when one in four Chinese men were hooked on opium. An opium pipe - drug use paraphernalia - an emaciated and frightened opium addict staring in the face of death and not looking much different than many new intakes that I have seen at 528.

Notice the chains. Does this guy look like he can just stand up and walk away? These chains are an earlier depiction of opiate drug addiction and physical dependence - binding a sick person to the same substance that is killing them.

Think this only happens to a bunch of reckless drug addicts?

My doctor started me on those pills for pain. Each time I said wasn't feeling well - he increased the dose - and added new pills. It wasn't long before I was taking them all the time for any reason - and I would feel horrible if I tried to stop them. I was using them too much and my life started to unravel. That was when my doctor discharged me from his office - and I had to buy pills on the street. Things then got much worse - until I finally decided to come here for help.

I could copy / paste that paragraph into dozens upon dozens of clinical charts at 528. Exactly the same story would fit perfectly to each of the patient files. I have heard this same story so many times that I now feel impatient when I hear yet another client starting into their version of it.

Think that you - Won't get addicted if you take them as directed? To anyone who has any belief in any amount of vulnerability to addiction that may exist in the biology of some people - this is the exact same thing as telling someone that they will not catch a cold - as long as they do not sneeze. The statement is complete nonsense.

Both substance addiction and physical dependence are the result of interaction between a vulnerable brain and a consumed chemical substance. There is no way to predict who will have to deal with these complications of treatment and who will not.

There are of course many other ways that people young and old start to use - abuse and misuse these kind of prescription drugs. The reason for this is that do not just treat pain. They make everything feel better - and many in this community live on a daily basis with various forms of distress. Opiate drugs have always been foolishly used in self treatment of emotional pain or for recreational purposes.

If you want to understand why so many sick and disturbed people are coming forward for methadone treatment at this time - there is not very far to look. Prescription painkiller drugs have never been so commonplace in this community as they are now - or so easily available for the asking. This was not always the case.

It was not until the mid 1980's that a handful of doctors working in our local academic centres - initiated a change in prescribing habits - greatly expanding on the indications to prescribe these drugs. It is our educational institutions that have led the way ever since - as the regional training centre for medical students and community physicians - in how to prescribe these drugs. As far as southwest Ontario is concerned - London is the epicentre of this shift in clinical practice.

Not all doctors have adopted the broader indications for the prescription of these drugs. Many have not. But of those who have - many will prescribe them with complete disregard to their potential for long term complications - or to the safety of reckless, naive, young or vulnerable persons also living in this community.

This change in physician prescribing practice is the reason why these pills - more similar than different to heroin - are now so widely available in London homes - on the streets and in our schools. Many - if not most of the needles picked on the downtown streets of London - contain these prescription drugs. This is the reason behind the huge number of sick and distressed people coming through the front door of Clinic 528 - and for challenges faced by many other of our clinical and social services.

For every person now in treatment for troublesome dependence on these drugs - it is my opinion that there are at least five or six others with the same problems - but who have not yet come forward for help. Their problems are not going to get better without intensive involvement in one type of treatment program or another. These problems only get worse - until they find some way to discontinue use - and to stay stopped.

From my perspective - this is a home grown, iatrogenic public health mess that has been allowed to grow by means of misinformation, carelessness and neglect. And as bad as things may now be - it is also my opinion that we have only begun to see the complications, costs and consequences that will result from the commonplace availability of these drugs in this community.

I was involved in the organization and administration of Clinic 528 for several years - largely in program planning - and have in fact missed only one staff meeting in the ten years since its inception as an idea. I am not an owner of the facility - have not held responsibility for the management of its physical property - and am no longer involved in its administration.

In my experience - the greatest single challenge to the facility has been the huge and unanticipated surge of need that has come to our door. We could have started to turn people away long ago. But we chose to not do so - rather to streamline our working processes and to provide a basic level of care to the larger population in grave need.

We could also have saved ourselves a great deal of grief by discharging clients who seem determined to die by other addictions - or just by requiring a residential address for enrolment. Our decision has been to provide a simple prescription, basic education, motivational counselling and support to any person requesting opportunity for recovery. For some of our clients - just not having a needle in their arm today is a success. I believe that we are all safer and better off by this approach - and see no benefit to anyone by discharging such clients back to nowhere.

Many others do well - very well. My practice is now located on the second floor of 528 Dundas Street - offering maintenance treatment, advocacy, counselling on addiction recovery and relapse prevention to near four hundred clients - all of whom have broken free of their chains through the opportunity provided by the Clinic 528 program. Hundreds more have come and gone.

My clients are aged seventeen to sixty-seven. They include high school, college and university students - plumbers, electricians, roofers and most other trade skills - salespeople, waitresses, hairdressers, nurses and business managers - brothers, sisters, husbands, wives, couples, parents and their adult children - and some entire families in treatment. I also see many healthy people in my office who were previously homeless - living in London shelters or on the street.

I have never seen so many people recover from such a severe state of sickness - to such an improved condition of health and social contribution - in any setting in which I have previously worked. It has been the most rewarding occupation of my career. All that most of them want to do once their head is clear of these drugs - is to go back to school, to work or to regain their role as a responsible parent - sometimes to buy their kids a nice Christmas present for the first time in years.

Yes - they are very sick when they first come in - restless, angry, impatient, discontent, anxious, secretive, fearful and ashamed. I understand the discomfort of the community in passing this sickness on the street. But ease of access, a flexible and extended attendance schedule, simple and streamlined program processes are all strategies that have proven successful to engage and retain highly unstable clients in necessary treatment.

Regardless of the pace of progress - all are better off in program than not. Those that persist in their addictive behaviours engage in destructive and dangerous conduct all day long and wherever they are at. This is the nature of their condition - and why they require more help than can be offered at one location.

In my opinion, the currently proposed bylaw is not about most of the things written in its pages. It is more about beliefs and non-beliefs about the sickness of addiction - about sick people or bad people and how to try and control them. The proposal is about property values and not wanting a sick underbelly of this community to be so visible as they spend three minutes in pharmacy each day. It is about the kind of community that we will be - one that provides accessible opportunity to those in despair - or that stigmatizes, marginalizes or shuffles them off to some out of the way industrial area.

The proposed bylaw will certainly affect ease of access - and reduced access to treatment will mean greater sickness in the community. Even the discussions surrounding this effort have stirred malicious and misinformed comments, uncertainty, fear and shame - all factors that discourage addicted people from engaging with or persisting in treatment.

One of the noticeable trends that we have seen over the years - is younger and younger people coming in for treatment earlier in their troubles - and before their lives completely unravel. This shift is an advantage to everyone - but is only discouraged by the tone of discussions surrounding this bylaw proposal.

There are locations in this city that buy, sell and barter thousands of prescription pills every day of each week. But if this city cannot even find a way to deal with a handful of peddlers on a corner directly across the street from our huge new police services block - then I would suggest it is past the time for blaming 528 for providing treatment to the people who buy these pill in their sickness. It is a time in fact when services need to be expanded and improved upon.

The problems associated with these drugs are going to get much worse before they may or may not get better. Those who are trying to recover will need dispensing pharmacies near to their residence - as well as extended hours at treatment facilities - if they are expected to continue at work or in school. With all of the complaints about periodic line-ups to the pharmacy at 528 - why are there still only a handful of pharmacies in this city who will dispense methadone - and why are we making it so difficult for new dispensaries to open?

Many of the issues cited in the proposal have little if anything to do with methadone treatment. The most severely ill and addicted - living in transient housing or on the streets - are going to require much broader access to harm reduction facilities like needle exchanges, retrieval strategies and safe injection sites.

There are other regions in Canada who have adopted meaningful legislation to curb the careless prescription of oxycodone based drugs. Other public health units have launched programs to properly educate their community about the risks of these drugs. There are hospitals that exercise caution or have restricted the routine ambulatory prescription of oxycodone type painkillers - and there are many responsible physician offices here and elsewhere that similarly do so. And there are communities that have responded to similar problems with increased access to treatment and strategies for harm reduction.

London is on the verge of legislation that will further stigmatize and isolate a large, frightened and vulnerable segment of its community - a proportion of whom have done nothing but suffer a complication of their doctor's treatment - and the majority of whom are sick from the use of pills that have been prescribed and dispensed to some other person also living in this community.

Aside from the fact that this approach will fail to contain the problems that it hopes to hide away - the proposed bylaw will most likely prove itself an expensive legal quagmire - and eventual embarrassment for a city that has the professional expertise to do much better.

So for what they are worth - these are my comments about London's currently proposed bylaw - and that I think would be best scrapped as shortly as possible.

John Craven MD