Feb. 27, 2001 -- Today, more than 17,000 Americans are marking time on a waiting list for liver transplants. About half of them are on the list because they have hepatitis C, a viral infection that silently stalks and destroys livers in about 10,000 Americans each year.
Hepatitis C is a blood infection: People get it either from transfused blood that carries the virus, or from infected drug users sharing needles, with heroin addicts high on the list -- a medical fact of life that is causing controversy in the tight-knit organ transplant community.
It's a well-known fact that the number of people waiting for new livers is far greater than the available supply of donated organs -- on average, only about a third of those on the list will receive new livers -- the rest will die waiting.
With so few livers and so much need, transplant programs jealously guard each place on the list, carefully assessing candidates and choosing only those considered most likely to gain long-term survival with a new liver.
That selection process is creating a clash between those who treat the addictions that destroy livers and the surgeons who implant new livers.
The flash point is methadone, a legal drug given to heroin addicts as a substitute for the illegal drug. Methadone, which is taken orally, rather than as an injection, is doled out in daily doses to recovering addicts. It reduces the risk of them returning to heroin abuse and reduces the risk of spread of infection. Some take it for relatively short periods of time, while others are "maintained" for years.
Chemical dependency experts say methadone maintenance is a good medical treatment. Surgeons are not so sure. Many former heroin addicts who take methadone are not carefully monitored but instead are "using methadone as a way to stay legally addicted," says Richard Freeman, MD, and chair of the United Network for Organ Sharing liver transplant committee.
The United Network for Organ Sharing is neutral on the issue of whether methadone users should qualify for liver transplants, since it has "neither a positive nor a negative policy," Freeman says.
But at the New England Medical Center, where Freeman heads up the liver transplant program, the policy is more clear-cut. Freeman says the thinking there is that most persons on methadone maintenance should not get new livers.
"Our guidelines allow for individual evaluation, but in general we have not accepted patients who are on methadone maintenance except for certain circumstances." He says those circumstances include patients who "are in the process of coming off methadone, who are in active treatment programs, and who have family support."
Freeman's opinions are not unique. A survey of liver transplant programs suggests that many liver programs may be consciously or unconsciously discriminating against patients taking methadone. The findings are available in the current issue of the Journal of the American Medical Association.
The authors, Monika Koch, MD, and Peter Banys, MD, conducted a mail survey of 97 adult liver transplant programs and found that although 56% of the programs said they would accept patients who were taking methadone, almost a third of those that accept patients would require that the patients discontinue methadone as a precondition for getting a new liver.
But requiring people to stop methadone is bad medicine, according to Mary Ellen Olbrisch, PhD, a consultant to transplant programs and an associate professor of psychology and surgery at Virginia Common Wealth University in Richmond.
Olbrisch says she thinks the anti-methadone policies are the result of "prejudice against patients with a history of opioid abuse." She says the prejudice is probably more common against patients with a history of injection drug abuse, the very patients who may need a liver transplant because they have hepatitis C.
Douglas Hanto, MD, director of the liver transplant program at the University of Cincinnati, shows that Olbrisch is fighting an uphill battle. "[Our program] has taken the position that patients on methadone are not candidates for transplant," he tells WebMD.
Hanto says, however, that "it hasn't come up as an issue where a specific patient has been turned down, but it has been discussed, and our reasons are that we think if someone is on methadone for a long time, they are simply substituting [for the drug], and we think they have not adequately dealt with the chemical dependency issue."
Ironically, Olbrisch says that a patient who is in a methadone program may be a "better risk for liver transplant. These are patients on whom we have a number of drug screens, persons who are closely involved in a drug treatment regimen; they are definitely not in denial."
By contrast, "we just have to take the word of the alcoholic about how clean they are," Olbrisch says.
Hanto disagrees. "In Ohio, we require that all substance abuse patients be in well-documented programs. We have very tight criteria, and all patients are very carefully evaluated and screened," he says.
Olbrisch says that attitudes like Hanto's may change with experience. "We actually have only a few of these patients at this time, and we will need to accumulate more data ... before we can make recommendations about guideline criteria," she points out.
This lack of experience also is noted by the authors of the survey. They write that only 10% of centers had experience with five or more methadone patients, and currently there are only 102 methadone patients on the transplant list.