The methadone method 

Methadone and Suboxone treatments allow people living with opioid addiction to gain some control, get closer to stability and break out of a drug-seeking lifestyle.

THE COAST
  • THE COAST

In 2014, John spent the Christmas holidays alone, curled up in a ball on his bed. He'd run through his monthly opioid prescription in the first 12 days of December—like he'd done every month for the last two years of his life—and had to wait until the new year before he could go back to the doctor for a refill. This wasn't necessarily his rock bottom—that moment when a person suffering from addiction or substance abuse can fall no further into the effects of their disease. John says it's "hard to pick the worst day ever because there has been a lot of days where I thought it was the worst day ever."

But still, just two months later, on a Friday in March, 2015, he felt ready. He walked into Direction 180's Gottingen Street location, put up his hands, and asked for help. 

Kay was injecting $70-worth of the opioid Dilaudid and taking anxiety-fighting benzodiazepines like Xanax every day in early 2017. She and her boyfriend were getting to a point where they couldn't keep up with their consumption. On a Wednesday, she was home alone and watched Requiem for a Dream, the harrowing movie about addiction. She says she saw her options laid out in front of her: She could go on methadone to manage her drug use, or continue using until she went to jail or died. "Either way you look, it's like a grim reality." 

The next day she went to Direction 180's mobile bus clinic that used to park at various locations around the city and said "I need help, any at all," she says. "I would sell my soul, basically at this point." 

Denyse moved from Dartmouth to Toronto in 2015 to try and get away from her opioid addiction and the partner who had first introduced her to the drugs. She says there were methadone clinics everywhere, "it was so accessible. It was like having a Tim Hortons on every block." Seeing the clinics made her think, "Oh, I can get help." 

For people who are suffering from addiction, turbulence is the norm, stability is a stranger and the road to recovery—whatever that looks like—is an uphill battle. A mountain that feels like someone (the world) is standing at the top hurling rocks (unrealistic expectations weighed down by stigma) at you.

Leah Genge is a physician and addictions specialist in Halifax, where methadone clinics are both less common and less accepted than Tim Hortons. She works at Direction 180 and the Mobile Outreach Street Health clinic and in her own practice in Spryfield. All three places take a harm-reduction approach: meeting people where they are and as a result reducing risk for the patient and the larger community. In treating the disease of addiction, Genge insists that recovery is a spectrum. What success looks like depends on the patient. For some it means using opioids safely or being able to have dignity in the places where you use—having more control over your life. For others, it's complete abstinence. And there are "all shades of grey in between," Genge says.

The latest national guideline published by the Canadian Medical Association Journal recommends opiate agonist management or narcotic replacement therapy for treating opioid addiction. Treatments like buprenorphine-naloxone (known more widely as the name-brand Suboxone) or methadone. It's trading one opioid for another, less harmful and more stable opioid. In Nova Scotia this year almost 700,000 suboxone and methadone prescriptions have been filled. (Suboxone prescriptions have increased by 35 percent from last year when the national guideline recommended it as the best-practice first option).

Today, John, 57, takes methadone daily. He started at Direction 180 for daily doses for three months. After going three months with no opioids other than methadone in his system he was able to start taking some of his prescription dose, methadone mixed with Tang in small brown tamper-proof bottles, home. He now goes to Regency Park Family Practice for a monthly prescription, gets it filled at the pharmacy, and takes it every morning, going back to the pharmacy for "witnessed consumption" on the fourth and seventh day. He relapsed a few times last year, taking opioids that get him high the way methadone won't, and knows he'll relapse again. But after 20 years of doctor-prescribed opiate addiction, he's just grateful—and shocked—he's still alive.

Denyse, 41, is on a very low dose of buprenorphine. It's taken daily in her apartment, in the form of a small white pill. Like John, she's allowed to get several doses when she fills her prescription. She's been in some form of recovery for the last four years and is now working part-time while also receiving income assistance. She fills her days with group therapy and addictions support meetings to keep busy and a sense of routine.

Kay, 26, who asked that her real name not be used, is on a methadone program. When she first spoke to The Coast she was a month away from landing benefits at her full-time job, but she was just laid off. "My painkiller/Xanax abuse caught up to me," she says in an email. She's still injecting Dilaudid and other opioids sometimes on the weekend and taking Xanax daily, and is not quite convinced that methadone is the best thing for her—she calls it her "liquid handcuffs."

Opiates like street drug heroin or prescription drug oxycodone work by latching onto neuroreceptors in the body: When the drug is present, the receptors send signals of euphoria to the brain. That's the high. But when the drug wears off, the receptors send desperate signals begging for more—that is withdrawal. When methadone and buprenorphine, therapeutic opioids, bind to the neuroreceptors instead, they trick the body out of experiencing withdrawal symptoms, while stopping short of sending any sort of euphoria signal to the brain. 

The first time Canadians could get this treatment was in 1959. In Prescriptions, Power and Politics: The Turbulent History of Methadone Maintenance in Canada, Benedikt Fischer writes about Robert Halliday's fairly "inconspicuous" Vancouver-based study using methadone, a new synthetic opiate, in the management of short-term withdrawal from opiates. Halliday maintained that abstinence was not the aim of the program, and likened the treatment to insulin treatment for diabetics—an analogy health practitioners and advocates are still using today, advocating for addiction to be seen as a disease, and Suboxone and methadone its medicine.  

Since then, access to the treatment has been a cycle of growth and restriction. A national commission in 1960s saw momentum build behind methadone treatment, but by the end of the 1970s that momentum was dulled, restrictions were tightened and the number of patients was down. Only recently has Nova Scotia eliminated requirements for physicians to have a special license to prescribe methadone, and the number of Suboxone and methadone prescribers in the province increased from 67 to 208 and 139 to 249 respectively as a result. Nova Scotia also made changes to income assistance programs to support people affected by addiction and increased some areas of funding to community supports. But these changes have only happened in light of a continent-wide opioid crisis that killed 12,800 Canadians between January 2016 and March 2019. 

In 2018, someone in Canada died every two hours due to opioid-related death. 

The cycle of availability of care has been influenced—like many health care issues that have been politicized (see: abortion)—by the notion that addiction is a matter of morality or even criminality. If addiction is seen as a failure of will or an anti-social lifestyle choice, replacement therapy enables bad behaviour. But when addiction is considered a disease and all the physiological and environmental factors that contribute to the disease are considered, access to care—and recovery—increases.

Kay was introduced to opioids through hydromorphone—AKA Dilaudid—in February 2016. She started snorting the drug and by the end of the year was injecting intravenously. 

"You get dependent, and then you get addicted to a drug. And you have to work to make money for the drug that you have to get, and the drug takes up all your money and then you can't go to work if you don't have a drug because you're sick," she says. "It was just a horrible, horrible cycle."

The drug quickly changed from something she loved to something she needed to survive. 

John was prescribed opiates—Percocets—by his doctor over 20 years ago. He'd had back surgery as a result of an injury while serving in the Armed Forces. "Within a month I was addicted." 

After moving to Europe and returning to Halifax, he learned that the rules around prescribing the opioids that had gotten him hooked in the first place had been tightened. "I got a rude awakening," he says. He was so addicted by that point, that the change scared the hell out of him. 

The doctor-shopping he'd done to fill his prescriptions in Europe wasn't an option. Splitting his prescribed pills in half so it appeared as if there were more didn't work. He bought a dispenser, but ended up smashing it open. He left pills with friends who would eventually give in to his begging—they had to. And getting his fix from outside the medical system that had cradled his habit since it began was never an option for him, either. So every month he'd just wait, in agony, for 10, 12, 18 days until he could get his prescription refilled. 

Waking up the day after finishing his last pill was the worst feeling for him. Anxiety sets in, John says, and quickly takes over. "You feel like your heart's going to be ripped out. It's awful."

Opioid withdrawal is like the "world's worst flu," says Genge. "People just feel like they're dying." On top of the crippling anxiety, John says it's no sleep, the shivers, not even enough energy to shower. 

Kay says there's flu-like symptoms, cold sweats, watery eyes, running nose, restless leg syndrome, "which progresses to restless body syndrome to the point where it's like, I literally want to rip the skin off of my body because that is how uncomfortable it makes me feel." 

When neuroreceptors are getting opioids that aren't methadone or Suboxone, the brain is being signalled to send euphoria all over the body. Kay says it's like a warm feeling going through your veins, "like stepping out into the warm sun or like putting like a warm blanket over you. And like everything just feels OK." When neuroreceptors aren't getting those drugs, they signal the brain to scream for more, which manifests in furious withdrawal symptoms. 

Darren Dileo, staff pharmacist at Scotia Pharmacy on Gottingen Street says the addictive properties of opioids causes your life to become focused on drug-seeking behaviour. "That's all you really are wrapped up in." 

"As far as employment, family, hygiene, nutrition—everything goes out the window, because you're completely focused upon getting drugs because it's a sickness...and you get very ill if you don't."  

"Why don't you just quit?" a friend who loves him once asked John. 

It's like "telling somebody who loves doing carpentry to stop doing carpentry or something they love. You just can't do it," John says.

"Your brain is telling you, it wants something...and if it doesn't get it, it will put you through hell."

It was a game of president and prisoner. John was both. 

"I want to be sober. So bad," says Kay. "But I just have a hard time wanting to want it." She pauses to think about this, and then asks herself: "What clicked for them that can't click for me? Am I destined to have this horrible fate? Do I have yet to somehow hit another rock bottom?

"It sounds so sick to say," says Kay—she knows it isn't true—but says sometimes she thinks it's easier to be addicted, "Because you only have one goal. You only have one mission. You only have one thing that you need to focus on. But when you come out of that you're like, you kind of have to face reality." 

There's a lot of inner conflict for someone who wants recovery, says Denyse. "And there was a lot of failure along the way." 

After living in Toronto, Denyse moved to Bradford, north of the city, and went to a three-week harm-reduction rehab in Etobicoke. She didn't want to go back to where she'd been living before—with her partner, who had been the first person to give her opiates—so she wound up at a homeless shelter in Scarborough. "It was scary being there by myself," she says. "There was drugs everywhere."

Denyse lived through a pattern of treatment, rehab, relapse, treatment, relapse and rehab for almost four years. She spent a lot of that time fighting her own inner dialogue, telling herself she was squandering this good thing. 

"I would go from like feeling hopeful to using, and then just trying to use so much that I wanted to die because I felt so bad about, like, losing that opportunity to get clean.

"I was in a fog. I was in a daze. It was just, it seemed like an enormous mountain. And I just didn't even know how to put one foot in front of the other. I didn't know what the first step was. And to go one day without using was terrifying," says Denyse. 

"The fear of the unknown is greater than the fear of death."

That fear is fuelled by instability—instability that existed before addiction did, or came along with it. Drug-seeking behaviour knows nothing of stability. 

Being able to help people means looking at the fullness of their life, says Genge. Mental wellness, physical wellness, housing, hygiene, money.

"We put these expectations on people to live in this fullness of their recovery while they're still struggling with basic survival," says Genge. Like when you're sick or feeling your worst, you want to be home, in your bed. "It's just, it's mind-boggling that that we don't think about those things when people are in the most vulnerable place in their life."

Before treatment, the only thing Denyse had done every day was use substances. The first little form of structure she had was going to the methadone clinic every day. It was like "a purpose and a reason to get out of bed." She found having to get to certain appointments at specific times "very stressful."

In spring of 2018, Denyse's parents offered to fly her back to Nova Scotia on the condition she start on a Suboxone treatment program right away and go to the Crosbie House rehab centre in the valley. Rehab alone cost her family $8,300. Afterward, she rented a one-bedroom apartment in the basement of her mom's house. Sheltered, she could apply for income assistance and was able to stick to her opiate agonist management therapy. 

Until then, her life was so volatile that she lacked the ability to even hope for something different. With nowhere to live, sleep, no food to eat—when she was in survival mode—stability was a stranger. 

"If I'm unable to sleep properly, or if I'm not eating, how am I then able to get up at a reasonable hour of the day to go to an appointment? If I don't have any money how am I able to get bus fare to go to certain places that have the resources?

"If I'm homeless, how can I possibly get resources?" she asks. "They all want an address or they all want a phone number."

After rehab, while Suboxone was doing its job of eliminating cravings and withdrawals while not giving any sort of high effect, Denyse began to find stability. She was waking up at the same time every day, eating and sleeping and showering. 

"That stability made it sort of like a new snowball, and the snowball isn't going in a bad direction, it's going in a good direction."

For Kay, the ability to go get her methadone from the pharmacy, outside of the set hours of Direction 180, meant she could get to work on time, and was helping her keep her job—until recently. But her liquid handcuffs still have her conflicted. She's still addicted to opiates—these ones are just Tang flavoured, don't get her high and mean she can't get high off other ones, either. "And it's that they last longer so you can be more functional, which is kind of ridiculous. But it's like what else do you do? You know?" 

She lives in a "weird limbo," wanting the thing she knows she shouldn't want. Taking the thing she wants but also doesn't want. She's reluctant to get her methadone, and that itself is disheartening. "Why can't I get this demon like off my back?" she asks.  

click to enlarge SUBMITTED
  • SUBMITTED

S mall shifts in access are making things easier for people in recovery. Kay can earn "carries" of methadone, so she isn't locked into getting somewhere at a certain time to get her daily life-sustaining medicine. Small changes in provincial policy meant Denyse qualified for Income Assistance and could get a Halifax Transit bus pass for free through the Department of Community Services—helping her get to her appointments on time. Shifts in municipal policy meant Denyse could afford Halifax Transit's low-income transit pass and get to her appointments on time. Increased attention from veterans affairs provides John with a psychiatrist and a psychologist on top of his methadone treatment, without whom he says he'd never have gotten anywhere. 

Darren Dileo has been a pharmacist since 1984, and harm-reduction has been the approach of choice where he works since the early 2000s. "It's getting better all the time. When we first started out there was nothing. Nothing, you know?" he says. But now, that's not the case.

It seems the pendulum may be swinging in favour of improved services—but this only comes on the heels of Canada's deadly opioid crisis. 

The over-prescribing of opiates, which saw an outbreak of addiction internationally, then led to a clamp-down on prescribing. (See pending lawsuits in the US and Canada against opioid manufacturers for producing and pushing a product they knew was lethally addictive). The clampdown has led to a decrease in medical supply, leaving a gap to be filled by a burgeoning clandestine production of pills, notably Fentanyl and other synthetics. As of the beginning of October, 40 Nova Scotians have died from confirmed and probable opioid-related causes this year. Access to safe services is still limited. 

LENNY MULLINS
  • LENNY MULLINS

This fall, HaliFIX Overdose Prevention Society opened up Atlantic Canada's first Overdose Prevention Site—notably without provincial or municipal support. A province-wide doctor shortage means there are overworked physicians who don't have time to take the training necessary to prescribe buprenorphine or methadone, and thousands of Nova Scotians lack access to a primary care provider. And there are the risks: methadone can be dangerous to people whose tolerance has decreased—which can happen in a matter of days—or people who have never tried opiates. Suboxone—made with Naloxone, which eliminates its ability to be diverted into the illicit market—is safer but still prescribed less than methadone.

Housing costs continue to rise and HRM's plan for affordable housing won't see any concrete action until next year at the earliest. The Out of The Cold Shelter—a vital resource for folks who are using substances that aren't allowed to stay in some other shelters—still needs a location.

Rocks hurled from the top of the mountain that make recovery challenging keep coming. Front-line workers and advocates share the importance of acknowledging the weight stigma and systemic neglect lend to this challenge. Harm-reduction is gaining steam as an appropriate and necessary treatment for addiction—like Halliday insisted 60 years ago in 1959. Despite all of this, the health care issue continues to be moralized.

Kay still blames herself and nothing else for relapsing. It's a daily battle with herself, and everything coming at her from the top of the mountain. Some days, she's able to remind herself she's worthy of recovery, like she did the very first day she went to the Direction 180 bus, telling herself: "I deserve to be here and need to be here as much as everybody else."

"Just because somebody's addicted to drugs doesn't mean they're any less worthy of a shot at coming back to life," she says. "A shot at maybe like, getting your shit together. You know, just moving past it."

Perhaps the rock bottom she thinks she must hit before it "clicks" isn't real. Worst days happen over and over, and the magic moment of being ready for recovery could be in the next 10 minutes­—or 10 years. But imagine a life where addiction and addiction treatment exist within a framework of stability. Will we let go of the desire for people to wither to their absolute worst before we decide they're ready for—or worthy of—their absolute best?

Caora McKenna is The Coast's city editor. If you want to share your addiction story with The Coast email addictionstory@thecoast.ca.

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