METHADONE PATIENTS GET A SHOT AT LIVER TRANSPLANTS

A policy shift by Ontario medical authorities may give recovering heroin
addicts who need liver transplants a new lease on life. Until recently,
people in methadone programs were routinely excluded from the province's
liver transplant recipient lists.

A U.S. study released earlier this year showed that almost half of liver
transplant programs do not accept methadone-treated patients, and that of
those that do, most require that the patient discontinue the drug first.

Transplant specialists cite many reasons for this exclusionary policy, both
medical and psychosocial. Dr. Douglas Hanto, director of the liver
transplant program at the University of Cincinnati, sums them up this way:
"[Methadone users] have not adequately dealt with the chemical dependency
issue."

In other words, they're still addicts.

But many U.S. and Canadian addiction specialists, including Addiction
Research Foundation clinical director Dr. David Marsh, disagree.

"Methadone should be regarded as any other medication," Marsh says.

Asking a methadone-taker to "detoxify" prior to assessment for transplant
raises an intriguing question: what is toxic about methadone? Experts say
methadone does not damage the liver and allows for a socially integrated,
healthy lifestyle. Available evidence on relapse rates shows that about 80
per cent of methadone clients remain heroin-free four years after starting
the program.

Sticking to a methadone regimen takes an impressive degree of cooperation
with the medical system, says Dr. Les Lilly, a transplant hepatologist and
the director of Toronto's liver transplant program.

"These patients have to be extraordinarily [medically] compliant just to
pick up their methadone," Lilly says.

Dr. Mary Ellen Olbrisch, a Virginia-based professor of psychology and
surgery, puts it another way. "They are definitely not in denial," she says.

Yet, until last March, the Toronto liver transplant team was among those
who excluded methadone users and sometimes refused to assess them for
surgery. The policy was publicly questioned this year by two prominent
Toronto addiction medicine specialists, both of whom saw patients die for
want of a new liver. The patients had been told that their methadone
dependence ruled them out of the program.

One of the physicians who spoke out, Dr. Meldon Kahan, described the policy
as "institutionalized discrimination."

At the time of Kahan's challenge, the policy was already under intense
scrutiny by the team. Lilly says "considerable debate" on the topic began
over three years ago. In March 2000, the annual meeting of the Canadian
Liver Transplant Study Group focused on methadone patient transplants, and
participants agreed to review the experience in their own programs for
presentation this year.

When the group met again, they reached a consensus that methadone patients
would no longer automatically be ruled out from assessment for transplant.

"We consider each case on its own merits," says Lilly, describing the new
approach. "If the patient has shown no relapse for two or more years, does
not have other significant illnesses, is in good psychological health and
has good social support, then we consider the patient a good long-term
candidate."

Lilly cautions that other problems -- like "management of narcotics [for
pain] around the time of the transplant" -- sometimes go hand-in-hand with
methadone use, but he says the team is willing to consider these issues
along with all the other criteria.

This change of policy aligns the two medical teams in Ontario that perform
liver transplants. The province's methadone users can now expect to receive
equal consideration to those taking other legal drugs, both at the Toronto
Hospital and its counterpart at the University Health Services Centre in
London, which has traditionally been more liberal on this issue.

News of the policy shift is likely to take some time to reach all referring
physicians, so the task will now be to alert newly eligible patients that
it's worth their while to seek assessment.

Physicians tell eye they previously learned of the London team's more
inclusive policy through "rumblings" or "other sources," rather than from
the teams themselves.

If the newly liberalized policy is disseminated in a similar way, methadone
users who need liver transplants may have to wait some time before they get
their moment with either one of Ontario's liver transplant teams.