British Columbia is quietly allowing some methadone users to switch back to an old formulation of the treatment five years after a new version it had adopted led to relapses and overdoses for some patients.
The province switched to the new formulation, called Methadose, in February, 2014, saying it was supposed to be safer. But patient advocates said it was not as effective for some patients in keeping withdrawal symptoms at bay. Many went back to using street drugs at the same time fentanyl began supplanting the illicit opioid supply, fuelling a crisis that has killed more than 5,000 people in B.C. since.
“People absolutely died as a result of this change,” said Garth Mullins, a drug-user activist, host of the podcast Crackdown and a member of the B.C. Association of People on Methadone, which has lobbied for a return to the old formulation. “How much did it contribute to the overdose crisis?”
Last May, the province made a third version of methadone, Metadol-D – a clear, colourless and unflavoured methadone formulation – eligible for regular benefit coverage through PharmaCare. And in October, it made the old compound methadone formulation available in exceptional circumstances to those who do not benefit from Methadose or Metadol-D. The 2014 change was announced publicly with news releases and notices to pharmacists, while the province made no announcements about the two changes this year.
Methadone is an opioid medication that, when taken daily, prevents withdrawal symptoms in people with opioid-use disorder. It can reduce the risk of harm associated with illicit opioid use – such as involvement in crime, sex work, unsafe drug consumption and blood-borne illnesses – and can help patients live a more stable life. About 15,400 people in B.C. are currently on methadone.
Christy Sutherland, education physician lead with the B.C. Centre on Substance Use (BCCSU) and a family doctor specializing in addiction, estimates that she had more than 100 patients on methadone at the time of the change and all responded poorly.
“They would come into my office and say, ‘This doesn’t have legs,’ and what they meant was that they woke up every morning in withdrawal,” she said. “Patients reported that the new methadone formulation didn’t last the whole 24 hours, and they were having cravings, and often relapse, and requested changes in their dosing.”
Patients generally reported that the old formula staved off withdrawal symptoms for at least 24 hours, and sometimes more. With Methadose, many reported withdrawal symptoms in 12 to 16 hours, according to studies and independent user accounts.
The original formulation consists of a white, crystalline powder that is diluted in a liquid – often an orange-flavoured juice – before it is dispensed daily to patients. Methadose is a cherry-flavoured liquid that does not require mixing. It is 10 times stronger than the old formulation, which means patients get the same amount of methadone in 1/10th the amount of liquid.
The B.C. Ministry of Health, along with the colleges of pharmacists and physicians and surgeons, said in 2014 that Methadose was safer because it does not require manual mixing and doses are therefore more likely to be consistent. It also does not need refrigeration.
But at least three published scientific studies of the change found that it disrupted treatment, led to an increase in illicit drug use and produced “considerable health and social harms.”
Ryan McNeil of the BCCSU and colleagues followed 34 people for six months after the change and found that about three-quarters reported increased withdrawal symptoms that fostered “severe suffering.” Some patients “toughed out” the symptoms until their next dose, but about two-thirds relapsed into illicit drug use, according to the Vancouver study, which was published in 2015 in the academic journal Social Science and Medicine.
As well, some reinitiated or intensified illegal activities such as drug dealing or sex work so they could buy the street drugs, the study found.
A related study published in 2017 in the International Journal of Drug Policy looked at the unintended effects of the change on addiction and HIV-related outcomes. Of 331 HIV-positive opioid users in Vancouver, the study found the formulation change led to “an immediate 11.5 per cent increase in heroin injection, and 15.9 per cent drop” in keeping to the required schedule in their anti-retroviral therapy.
Dr. McNeil, who was also a co-author on the second study, said the regulatory changes undermined treatment outcomes.
“The increased withdrawal symptoms after the methadone formulation change led many people to re-initiate, or increase their use of, illicit opioids,” he said. “This threw many people’s lives into chaos and made it difficult to access or adhere to HIV treatment.”
A 2016 study published in the journal Substance Abuse Treatment, Prevention and Policy surveyed 405 methadone patients from 50 harm-reduction sites in B.C. during the change and found that more than half “reported having worse pain, feeling more dope sick, and supplementing their methadone with other opioids.”
Chereece Keewatin had been stable on methadone for several years and relapsed into illicit drug use after the change. She tried other medications – slow-release oral morphine, buprenorphine – and spent much of her time fighting withdrawal before dying of an overdose this past February. She was 40.
“She was very frustrated, trying to find her way back to where she was before the change,” Mr. Mullins said. “Person after person got up at her memorial and said, ‘If they hadn’t switched her methadone, she would still be here with us.
“It’s hard to describe the feeling of feeling so sad, and so grief-stricken for losing someone, and so angry all at the same time.”
Mr. Mullins viewed the province’s move to allow some patients to return to the old formula as a small first step and said work continues to make it more widely available.
“I think they’re doing this to try to throw us a bone, or shut us up, because they’re not reintroducing it widely,” he said. “It’s on a last-resort basis. It’s actually quite hard to get.”
The Ministry of Mental Health and Addictions did not make anyone available for an interview. A short statement provided by the ministry and attributed to Justine Patterson, executive director of the Overdose Emergency Response Centre, acknowledged that the province “heard from people with lived or living experience that this transition did not work for everyone.”
The statement said that the province is “working with all partners to provide a full spectrum of treatment options to help people find a pathway and to hope,” but provided no details.
Dr. Sutherland described the change as a “catastrophe” that could have been avoided by involving people who use drugs in the planning and implementation process.
“It’s important that we, as clinicians and policy-makers and politicians, reflect on this and how badly it went, and to think about the future,” she said. “With vulnerable populations, you can’t change things in this way without a lot more caution and thoughtfulness.”
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