Charlotte Munro and her mom smiled for a selfie high above the frothy water of Niagara Falls. Amidst a difficult year where Munro endured both opioid withdrawal and a near-deadly infection, the weekend trip should have been a respite. But the getaway quickly turned sour because she was forced to forgo packing one essential item—her medication.

In 2014, after years of opioid use that began with a prescription for a fentanyl patch from her doctor for leg pain caused by necrosis, Munro decided to try methadone, one of the most effective medications in treating opioid addiction. It works by activating the same opioid receptors in the brain as drugs like heroin and fentanyl, except it’s slow-acting. This means that it can prevent withdrawal and reduce drug cravings. However, methadone itself is an opioid and subject to strict regulations in Canada and abroad.

These regulations limit access to take-home doses, forcing many patients to visit a pharmacy or clinic weekly or even daily to be observed while they take their medication. Patients are evaluated for signs of intoxication before they take their dose, watched while they take it, then their mouths are checked to confirm it’s been consumed. The purpose of these restrictions is to ensure methadone is used as prescribed, but the ensuing limitations on movement have caused some to refer to the drug as “liquid handcuffs.”

Daily observed doses shouldn’t render a patient completely tethered to their home pharmacy. Ralf Gerlach co-founded a harm-reduction organization in Münster, Germany just over 30 years ago and found his clients unsure if they could travel after starting methadone treatment. In response he wrote Methadone: Worldwide Travel Guide. He maintains that people should have access to this care wherever they go. “Denying freedom to travel is counterproductive to the goals of treatment,” Gerlach insists. “If doctors feel their patients are not stable enough for take-home dosing, courtesy dosing should be arranged at the place they travel to.” In practice though, courtesy dosing can wreck a two-day vacation to a nearby city.

Munro wasn’t prescribed any take-home doses for her trip, so she and her mom took a detour to a pharmacy near the Falls. Even though her doctor had called ahead and she had her ID and previous dose receipts, Munro’s methadone, which usually came in the form of a small, fruit-flavoured drink, hadn’t been prepared. She had to wait for the pharmacy to empty before being seen to. “I wasn’t given a fair turn in line like most people would get if you’re just going to the pharmacy to pick up a script,” she says. “I felt like a second-class citizen.” In her eight months of taking methadone, that was the only trip Munro attempted to make.

“A change of scenery and feeling like you’re part of society is healthy, it’s needed,” she says. Research shows exposure to new environments—in other words, travel—can boost our happiness. But for those who take methadone, this kind of happiness may not be available.

Tens of thousands of people across the country take methadone to treat opioid addiction. Treatment duration can range from less than a year to decades. While Canada struggles to address an opioid crisis that has killed more than 30, 000 people since 2016, aggravated by a drug supply poisoned with fentanyl and, more recently, benzodiazepines that render naloxone ineffective, methadone treatment for opioid addiction has proven critical—cutting a person’s chance of dying in half.

Although strict restrictions on take-home doses are slowly easing, they continue to impose barriers which may lead to people experiencing interruptions in treatment or discontinuing it altogether. They also limit freedom of movement for those who do take it. The drug is treated differently than many other life-saving medications; retrieving a dose from the pharmacy or methadone clinic is burdensome and can be deeply stigmatizing. What’s more is that research proves that lessening these restrictions is better for patients.

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The first methadone treatment program in the world was founded in Vancouver in 1959. Residents of the Kitsilano neighbourhood originally set to house the clinic protested its opening and succeeded on the grounds that it would devalue their homes. At the time, two distinct conceptions of addiction treatment were clashing in B.C. Where the criminal model saw addiction as a moral shortcoming and pushed for indefinite compulsory treatment with a goal of abstinence, the medical model vied for voluntary treatment over punishment. The latter’s proponents suggested giving people addicted to heroin controlled levels of the same drug to help stabilize their lives, but this approach was ultimately rejected.

Amidst the discord Dr. Robert Halliday began treating patients for short-term opioid withdrawal with methadone. The drug had been synthesized by German scientists only 20 years prior and its efficacy for treating opioid addiction was mostly unknown at the time. Initially patients were given 12 days of methadone treatment to taper off the illicit opioid they were addicted to, but a few years later the clinic implemented what Halliday called “prolonged withdrawal”—allowing patients to take methadone for as long as they needed.

Both approaches had positive effects, however prolonged withdrawal saw more results, particularly for older patients who had been using drugs longer. Halliday cautioned against using abstinence to measure methadone’s efficacy. In a 1967 study that featured interviews with more than 150 of the clinic’s patients, he wrote that it’s “illogical to equate abstinence with a cure,” and compared methadone treatment for opioid addiction to insulin therapy for diabetes.

Instead, Halliday used factors such as relationships with family, work, a patient’s psychological wellbeing, and whether they developed healthy coping mechanisms to determine the success of methadone treatment.

At the turn of the millennium, professor Benedikt Fischer, a drug policy researcher, published a 40 year history of turbulent methadone policies in Canada. The success of Vancouver’s small-scale methadone treatment program prompted the practice to be widely accepted and 23 methadone programs opened across the country. In the early 1970s the government’s LeDain Commission published a series of reports on the non-medical use of drugs, including opioids, in Canada. It concluded that methadone was an effective treatment for opioid addiction and recommended a heroin substitution program when methadone was not adequate.

At the same time as the LeDain Commission, a special committee was struck to investigate methadone programs after a significant increase in the import of methadone into the country prompted concerns. It found that methadone was responsible for several overdose deaths and the widespread availability of the drug was brought about by private doctors without the knowledge to properly prescribe it. The committee thus recommended methadone guidelines that said it should only be prescribed to those with at least one year of opioid dependence, frequent urine screening for illicit drugs should occur with treatment, written prescriptions for methadone should be prohibited, patients must take the drug under supervision, doctors need authorization from the federal health authority to prescribe it, and any violation of the guidelines would be a criminal offence.

As a result, the number of patients taking methadone in Canada decreased from about 1,700 to about 1,100 in just three years. Over the years restrictions on people addicted to opioids continued—B.C.’s Heroin Treatment Act proposed compulsory treatment of up to three years for opioid addiction. While this was struck down in the province’s Supreme Court, policies restricting access to methadone persisted over the following decades.

In 1995, the federal government abruptly transferred oversight of methadone programs to the provinces. Since then, rules and regulations for methadone treatment, now one of several medications used to treat opioid addiction known under the umbrella term opioid agonist therapy, have developed differently in every province, with services in B.C. and Ontario expanding the most.

However, consistent throughout the country is the concept of contingency management, where people can earn take-home doses through meeting program requirements such as daily attendance at the pharmacy or clinic to receive an observed dose and frequent urine testing to check for prescribed and non-prescribed drugs.

“I was on methadone and suboxone for 18 years. And in that 18 years, I never once earned a take home dose,” says Toronto- based Andrew McLeod.

The restrictions on methadone and suboxone, a similar medication used in opioid agonist therapy, isolated McLeod. Being forced to make daily pharmacy visits means “you’re not engaging in society; instead, you’re kind of observing it,” McLeod says.

His rigid daily appointment made finding work difficult, with one employer never calling back after hearing he would be gone for half the day to visit the methadone clinic. It also affected his ability to spend time with loved ones. For nearly two decades, if McLeod wanted to be with his family at the cottage in Kingston, Ontario, away from his pharmacy, he had to secure heroin or fentanyl or else risk withdrawal, which he describes as excruciating. “It’s probably one of the worst feelings in the world. The withdrawal is what often takes people back.”

“Take the worst flu you’ve ever had,” he says, “then multiply that by 25 or 50. I’ve seen people violently sick.” At that point, McLeod explains, if he could not make it to the clinic in time or there was an error faxing his prescription, he had to find an alternative opioid. “I cannot live in that sickness.”

“One of the most dangerous situations is when someone decides for whatever reason, they want to abruptly stop their opioid agonist therapy,” says Dr. Vincent Lam, an emergency and addictions physician in Toronto. “Sometimes this can happen just because they’re frustrated with the limitations of the program.”

In the agony of withdrawal, patients are more likely to access another source of opioids, and with a lower opioid tolerance, this can be deadly.

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Alongside take-home doses for people who want them, activists in B.C. and across Canada are fighting for safer supply, meaning access to prescribed medication in lieu of potentially toxic illegal drugs.

In B.C., small pilot programs providing hydromorphone to those who use illegal drugs and are at risk of overdosing were established in 2020. However, the province continues to suffer the consequences of toxic supply with 2,300 people dead due to poisoned drugs in 2022. This year, B.C.’s government decriminalized the possession of small amounts of drugs, though activists and researchers warn that without an accessible safer supply, this is not enough.

After starting his career as an emergency room physician, Lam yearned for more continuity of care. He began working in addictions medicine and was surprised at the positive impact even a couple of weeks of opioid agonist therapy had on a patient’s wellbeing. Lam explains that addictions medicine has historically been the subject of additional oversight and scrutiny compared to other specialties, and says it’s a field which, in many ways, is stigmatized within the medical community.

Lam recently spearheaded the drafting of new methadone take-home dosing guidelines to make the program more accessible, replacing the former contingency method. These new guidelines are meant to help advise physicians in taking a more patient-centred approach. Instead of sweeping, generalized criteria for take-home doses, doctors are encouraged to look at factors such as whether someone can safely store their medication, a person’s overall stability, and their amount of time on methadone. Abstinence from non- prescribed drugs is no longer required to access take-home doses, although it may affect how many are permitted.

Changes to the guidelines were in part brought about by the COVID-19 pandemic. To reduce the risk of an outbreak, take-home dose allowances were increased for those who already had them and provided to people who were formerly only permitted observed doses. Researchers found that as a result, in Ontario the risks of treatment discontinuation and opioid-related overdoses were lowered.

A lingering point of concern for those critical of loosening methadone treatment rules is the potential for diversion. That is, methadone being acquired or used by someone it’s not prescribed to. While diversion does occur and improperly stored doses pose a public health risk, studies have shown that the main motivation for diversion is to provide safer drugs for others during an overdose crisis.“People have done it for me. I’ve done it for people who are dope sick. I’ve given them some of my methadone before to help them along so that they don’t have to do something else,” says Garth Mullins. Mullins is a board member of the B.C. Association of People on Opioid Maintenance and host of “Crackdown,” a podcast about drugs run by drug users.

Mullins first encountered harm reduction when he was 19, sleeping in a San Francisco park and using black tar heroin. At the time, syringes were difficult to find in the U.S., needle exchanges were illegal, and HIV was spreading among people who injected drugs. Mullins remembers using bleach in an attempt to sterilize needles and a match striker to sharpen them when they dulled. Then a group came by with buckets and new syringes. “It was a guerilla needle exchange. It was an act of civil disobedience in public health. It touched me and left a mark,” Mullins says.

While he has been taking methadone for more than 20 years and travelled abroad to Portugal with take-home doses during that time, Mullins understands why someone wouldn’t continue treatment. “A lot of people have just had enough. They don’t want any more people monitoring their lives, and want to get back a little bit of that dignity and self-determination…A methadone clinic seems like this weird hybrid between a place of healthcare and a place of punishment,” he says.

Alongside restricted travel, limited or no carries means someone fleeing disaster can’t access a supply of emergency medication. With wildfires burning more of the country every year and floods increasing in frequency and severity, this issue is growing more pressing.

The same restrictions that prevent people taking methadone from traveling are exacerbated for people in need of treatment living in remote regions. While opioid addiction is still prominent in rural areas, geographical barriers mean daily pharmacy access for some is impossible, like for Charlotte Munro, who was often forced to forgo treatment when her town’s pharmacy was closed on Sundays. If she wanted her medicine, she’d have to take a 45-minute cab ride to Stratford. Harsh regulations meant Munro’s access to methadone was precarious, putting her at risk of entering withdrawal. Her doctor was aware she was missing doses on Sundays, but that didn’t change her predicament.

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Almost a decade since Munro waited for a pharmacy to empty in Niagara Falls, the evidence of medical stigma sits in a box in her hallway. A few months after the weekend trip she became severely ill with endocarditis, an infection of the inner lining of the heart. Munro was turned away from three hospitals in one week. “They weren’t doing the tests, they were just thinking I was trying to get drugs,” she explains. She feels that her methadone prescription sparked bias.

The Friday of that week Munro fell into a coma and was rushed to Stratford General Hospital. She remained unconscious for two weeks and spent months recovering.

Now an activist and full-time student in Indigenous Social Work at Laurentian University, Munro requested her medical records from that period. She intends to go through the large box to understand why she was treated so poorly and present her findings, but hasn’t felt emotionally ready to relive the experience.

Even last year, however, Munro was traumatized by her treatment at the hospital while giving birth to her son. Munro wasn’t given adequate support with breastfeeding, her concerns were dismissed, and her chart noted that she had consumed alcohol during the pregnancy, which she says is untrue. “I’ve been so successful in my recovery… and then I go in there and none of that matters. It’s just what they see on paper. It was probably a flagged file,” she says. “I feel like it robbed me of certain things that I should have been enjoying with my son,” Munro recounts. “I was basically being looked at like an unfit parent.”

Both Munro and Andrew McLeod are co-authors on the new set of methadone take-home dosing guidelines, offering their perspectives for a more human- centred approach. McLeod is now a social service worker and addictions counsellor.

“Addiction, it’s got a lot of pieces to it. It’s not just as simple as changing carries and everything will get better,” McLeod says. Three-and-a-half years ago, he tapered off of methadone by slowly decreasing his dosage. The process was physically arduous as he endured some withdrawal, but he’s experienced new freedom. “Instead of having to make my way to this pharmacy, I could get up in the morning and I could go to work, or I could go to school. I was able to go visit my mom and my kids. I was able to go to college,” says Mcleod. Last summer, he went to B.C. for his first vacation in over 20 years, which he says is sad.

Alongside changes to how methadone is prescribed, McLeod believes that housing, access to education, jobs, especially for those with criminal convictions, and support to help families affected by addiction are all equally as important. Without housing, family, and employment opportunities, McLeod believes many will look at methadone treatment and think “what’s the point?”

However, the truth about the treatment of opioid addiction in Canada has been clear for more than 60 years. Abstinence- based, compulsory, and punitive programs are often ineffective. Yet echoes of these regressive policies remain and fester in strict contingency management, lack of patient-centred care, and a continued resistance to implementing harm-reduction from officials at all levels of government.

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Accessible opioid agonist therapy is a matter of life and death. While new person-centred and evidence-based methadone take-home guidelines and the decriminalization of small amounts of drug possession in B.C. are steps forward, the restrictions to travel Charlotte Munro faced nine years ago are still a reality to many across the country. The stakes could not be higher. An average of 20 people per day died of opioid-related overdoses in 2022. Safer supply programs that would provide people with unpoisoned drugs are difficult to access and although smoking is now involved in most overdose deaths in B.C., inhaled drugs are only permitted in a handful of safe consumption sites across the country. Ensuring freedom of movement for those who take methadone as well as improving access to this life-saving drug is critical.

An ocean away from Munro and McLeod, Gerlach still monitors drug policy in North America. Set to retire from his organization this year, Gerlach plans to continue updating the guide, now called Substitution: World Travel Guide, to include other opioid agonist therapy medications like suboxone. Poring over almost 200 sets of national import regulations and securing contact details of doctors and clinics is tedious work, but 26 years after the guide’s first publication, and in spite of limited funding, it’s helped thousands of people travel internationally. For Gerlach, it isn’t a question of whether someone taking methadone or other opioid agonist therapy medications should travel, but of how. “Travelling,” he says, “is a human right.”