British Columbia could serve as a model for effective treatment of opioid dependency for the United States, where opioid overdose is one of the leading causes of accidental death, according to a new report by Canadian and American researchers.
The report calls for both countries to expand "evidence-based treatment" for dependency on opioids such as heroin and, increasingly, prescription drugs including Oxycontin, Percocet and Vicodin.
"In the U.S., opioid related overdoses are now the second leading cause of accidental death behind only motor vehicle accidents," said Bohdan Nosyk, an associate professor of health economics at Simon Fraser University's Faculty of Health and lead author of the report. "It's become a really big problem and policy makers and treatment providers are scrambling to address it."
One of the report's chief recommendations is to expand opioid substitution treatment to office-based settings in the U.S., where methadone, for example, can only be prescribed and dispensed on an outpatient basis through federally regulated drug treatment centres. The number of methadone-prescribing facilities in the U.S. constitutes only about 8 per cent of all substance-abuse treatment facilities. And it is estimated that less than 10 per cent of Americans addicted to heroin and prescription opioids are receiving opioid substitution treatment, according to the report, titled A Call for Evidence-Based Medical Treatment of Opioid Dependence in the United States and Canada.
In B.C., the number of patients receiving methadone rose to about 13,000 in 2012 from 2,800 in 1996, the year office-based treatment was implemented in Canada, said the report, citing figures from the College of Physicians and Surgeons of B.C. In Ontario, the figure rose to nearly 30,000 from 700.
The model allows not only for increased ease of access to treatment, but enables further care of comorbidities, such as HIV, hepatitis C and psychiatric illnesses, according to the report. Treatment in a doctor's private office would also be less stigmatizing.
While doctors in B.C. can take weekend courses to become certified, there remain limited treatment options outside of the Lower Mainland, Dr. Nosyk said.
The report, which describes opioid dependence as a "chronic, recurrent condition," also highlighted the apparent risks in using opioid substitutions such as methadone to "detoxify" patients from opioids, despite that being discouraged in clinical guidelines.
"That's the scariest part," Dr. Nosyk said. "When people are on treatment, they're productively maintained, they're three times less likely to die than they are as a regular user. But that risk of death is actually highest in the first two weeks of treatment, when they're just getting used to the medication … and [in] the two weeks after dropping out. That's where detox becomes such a big problem."
He used three-week detox programs, considered a standard in many parts of the U.S., to illustrate. "Over the span of five weeks, people are exposed to really high risk of death for four out of five of those weeks," he said.
In B.C., a long-term, maintenance-oriented approach to treatment is generally advocated over abstinence. In a study of clients entering methadone programs from 1996 to 2007, about half had dose decreases toward the end of treatment, Dr. Nosyk said. Of those clients, only 2.5 per cent were successful in tapering their doses down to zero with no relapse within 18 months.
"It's unfortunate, but I think people need to be realistic about opioid dependence and recognize that it is a chronic condition," Dr. Nosyk said.
Health Minister Terry Lake was unavailable for comment on Tuesday, but the ministry issued a statement thanking the B.C. Centre for Excellence in HIV/AIDS for the report and acknowledging many of its recommendations are in line with measures the province is taking.
"The B.C. government is committed to continuing to work to improve our systems for substance dependence treatment, with a particular focus on opioid addiction, in order to help people with these addictions lead better lives," the statement read.
In the past few years, the ministry has worked with the College of Physicians and Surgeons of B.C. on its Methadone Maintenance Handbook, implemented a 10-year mental-health and substance-abuse plan and added Suboxone, a combination of buprenorphine and naloxone, to PharmaCare as an alternative medication for patients who cannot take methadone.