JUICED UP

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."