Many provinces are making it easier for doctors to treat patients addicted to opioids with a safer but more expensive pharmaceutical therapy, an area where Canada is a laggard internationally.
Methadone is the traditional treatment in Canada for patients hooked on popular prescription opioids such as hydromorphone and fentanyl. But the provinces are coming under pressure to improve access to an alternative addiction treatment that medical experts say is much safer than methadone and could dramatically reduce overdose deaths.
Suboxone is the drug of choice in the United States and France. While Health Canada approved it for sale in this country in 2007, the provinces have until recently viewed the drug as a second-line treatment, to be used for patients who cannot take methadone.
British Columbia – long seen as a leader in harm-reduction strategies – added Suboxone to its drug formulary as a regular benefit in October, making it a first-line treatment for opioid addiction. Provincial public drug plans pay only for medications listed on their formularies.
CANADA'S CHANGING VIEWS ON DRUG TREATMENT
Read the 1972 circular on Canada's shift in policy on the use of methadone to treat drug addiction. (Reprinted with permission from the Centre for Addiction and Mental Health archives)
B.C.'s College of Physicians and Surgeons introduced changes in July that make it easier for family doctors to prescribe Suboxone or generic versions. Previously, access was limited to doctors who are allowed to prescribe methadone.
Family doctors in five other provinces – Alberta, Ontario, Quebec, Nova Scotia and Prince Edward Island – are also allowed to prescribe Suboxone.
B.C. provincial health officer Perry Kendall said he hopes the changes will make it easier for people to get treatment, especially in remote areas where specialized methadone clinics are few. "There's big disparities around the province," he said.
Dr. Kendall declared a public health emergency in April, after a surge in overdose deaths from illicit drugs in British Columbia: 371 in the first half of this year, compared with 480 in all of 2015.
"We don't have any evidence that deaths are tapering off yet," he said.
The cost of treating addiction is rising in lockstep with mounting overdose deaths and the growing use of Suboxone, which is more expensive than methadone. The Globe and Mail has reported that spending on drugs to treat patients addicted to painkillers soared 60 per cent over a four-year period in Canada. Public drug programs spent $93-million on medications for addictions to prescription and illicit opioids in 2014, compared with $57.3-million in 2011, according to figures compiled by the Canadian Institute for Health Information for every province except Quebec.
British Columbia's drug plan spends $1,053 to $2,797 a year on Suboxone for each patient, depending on the dose, according to a Ministry of Health spokeswoman. By comparison, the province spends $118 to $710 per patient on methadone.
Suboxone is the trade name for a pill composed of buprenorphine and naloxone. It is safer than methadone because the buprenorphine curbs cravings and withdrawal symptoms and the naloxone blocks the effects of narcotics, making the product less likely to be diverted or abused.
Ontario added Suboxone to its drug formulary in 2012 for patients unable to take methadone. Since then, the number of recipients in the province's public drug program prescribed Suboxone has grown from 362 in the fiscal year ended March 31, 2012, to 6,956 in the current fiscal year, according to the Ministry of Health. Methadone use has grown more modestly, with 29,584 recipients in fiscal 2016 compared with 25,277 in fiscal 2012.
"We clearly are seeing a shift where people are getting prescribed more and more Suboxone versus methadone," said Bernard Le Foll, medical head of the Centre for Addiction and Mental Health's Addiction Medicine Service and leader of a national study evaluating treatments for opioid abuse.
However, methadone remains the dominant treatment because public drug plans tend to drive doctors' choices, Dr. Le Foll said. "If one is covered by the system and another is not," he said, "de facto you are orienting people to one prescription versus another."
Although Suboxone itself is more expensive, studies in the United States have shown significant cost savings because the requirement for daily dispensing and witnessed ingestion at a clinic can be eliminated much earlier than for methadone, says a recent report from the B.C. Centre for Excellence in HIV/AIDS and the Canadian Research Initiative in Substance Misuse.
Evan Wood, co-director of the Urban Health Research Initiative at the Centre for Excellence and an author of the report, said Canada has been relatively slow to embrace Suboxone because there are not enough doctors trained in addiction medicine who can push for new treatment options.
"Addiction medicine as a field is really still in its infancy," Dr. Wood said.
The Centre for Excellence is calling for more doctors to be trained to diagnose and treat drug addiction.
Michael Franklyn, an addiction doctor in Sudbury, Ont., said treating more patients with Suboxone is a "laudable goal." While there are more methadone clinics today than a few years ago, when he often had patients who travelled 1,000 kilometres by bus from Thunder Bay to Sudbury, many First Nations communities remain without access to the drug, he said.
Only a few doctors have been able to prescribe methadone because they need authorization from Health Canada to administer it and must be associated with specialized clinics. The federal government imposed the nationwide controls in 1972 after large quantities of methadone were diverted to the illicit drug market.
Once used exclusively for people addicted to heroin, methadone is itself an opioid. Used therapeutically, the drug reduces cravings for opioids, prevents withdrawal and blocks the euphoric effects of other narcotics.
But methadone was linked to 1 in 4 opioid deaths in British Columbia from 2004 to 2013, the Centre for Excellence report says. In Ontario, it was involved in 1 in 5 opioid deaths during the same period, according to figures from the chief coroner's office. Most of the deaths did not involve patients being treated for addiction with methadone.
The drug is also controversial as a treatment. Many medical experts believe doctors have a financial incentive to keep their patients on methadone. In British Columbia alone, physician billings for methadone maintenance program services totalled $16.8-million in fiscal 2016.
David Marsh, chief medical director of the Ontario Addiction Treatment Centres, a chain of 57 clinics throughout the province, countered that doctors do not get "any kind of financial reward" for prescribing methadone rather than Suboxone.
Nevertheless, he said, there should be no restrictions on prescribing Suboxone. "It ought to be left up to the physician to decide which medication is most effective for a given patient, the same as we would for antidepressants or antibiotics," he said.
Meldon Kahan, medical director of the Substance Use Service at Women's College Hospital, said Suboxone is becoming popular because of its relative safety and its convenience. Most methadone patients make daily visits to a clinic or pharmacy, where they take the drug under supervision. Patients on Suboxone can take the drug on their own after just a short period of supervision.
Tracy Taylor, who lives in Northumberland County in Ontario, has been on Suboxone since June, 2014. Her prescription costs $1,500 a year. She pays an annual deductible of $500, and the province's Trillium Drug Program, which helps people who have high prescription drug costs relative to their household income, pays the balance.
Ms. Taylor, 53, became a patient of Dr. Kahan's in June, 2014, when she sought treatment for her addiction to prescription painkillers and alcohol.
She credits his "holistic" approach, including asking her about her background and lifestyle – she was caring for her elderly mother at the time – with helping her to stop using opioids and alcohol.
"I didn't want to live like this any more," said Ms. Taylor, who works full-time in landscaping. "Dr. Kahan gave me hope."
She knew she was going to be okay, she said, when she did not crave alcohol or drugs after her mother died in November.
"She saw me sober and clean, and died knowing I was clean," Ms. Taylor said.