Pubdate: Thu,  29 Nov 2001
Source: Eye Magazine (CN ON)
Copyright: 2001 Eye Communications Ltd.
Contact:  http://www.eye.net/
Details: http://www.mapinc.org/media/147
Author: Abigail Pugh

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.
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MAP posted-by: Rebel