Family doctors and emergency physicians should treat opioid addiction with prescribed medication whenever possible, instead of referring patients to short-term detox centres with no follow-up care, according to a new Canadian guideline released Monday that addiction specialists say will help curb deaths from the opioid epidemic.
Until now, Canada has had no guideline for health-care providers at the front lines of this public health crisis, said a senior author of the report, Dr. Evan Wood, leaving doctors with few tools to support patients with opioid addiction. "It's a critical void that this is going to fill."
He added that opioid addiction should be treated as a chronic disease in doctors' offices, similar to diabetes or hypertension.
The guideline, published in the CMAJ medical journal, is similar to measures piloted in British Columbia over the past year. The report outlines a step-by-step approach that promotes the use of relatively inexpensive medication that reduces cravings for opioid drugs, said Dr. Wood, director of the BC Centre on Substance Use.
It recommends a pill that contains a combination of buprenorphine and naloxone, commonly known as Suboxone, dissolved under the tongue, as the "preferred first-line treatment" for opioid addiction. Doctors in every province, other than Saskatchewan and Manitoba, can prescribe Suboxone without special training. The second-line option, methadone, and the third – slow-release oral morphine – each require training and a federal exemption to prescribe them.
The guideline advises against detox programs that discharge patients after several days, with no further addiction treatment or medication to support recovery. This short-term approach is "extremely common" in Canada, Dr. Wood said. But at least 80 to 90 per cent of patients will relapse after discharge, with decreased tolerance for opioids after detox.
If they return to opioid use, even in quantities they have tolerated in the past, "the likelihood of a fatal overdose is quite high," he said. "You're better off doing nothing than admitting people to a detox program like that."
In British Columbia, the recent push to increase access to Suboxone "has saved untold lives," said Dr. Keith Ahamad, a family physician who treats opioid use disorder at Vancouver Detox and the Rapid Access Addiction Clinic at St. Paul's Hospital. While the overdose rate has continued to climb, Dr. Ahamad, a lead author of the Canadian guideline, said patients taking appropriate doses of Suboxone and methadone "are not the ones that are dying."
Compared with methadone, Suboxone carries less risk of overdose, has fewer side effects and cannot be easily crushed and injected. Patients can take the medication at home, whereas methadone treatment involves consuming a liquid drug in front of a witness. Daily trips to a pharmacy for methadone "can be a huge barrier for people to employment, and to recovery," Dr. Wood said. "People call it 'liquid handcuffs.'"
The main disadvantage of Suboxone is that patients must go through partial opioid withdrawal before starting treatment, enduring symptoms such as headache and diarrhea. Methadone treatment, in contrast, can start any time.
Suboxone is more expensive than methadone, although both are covered by provincial drug plans. Costs vary by province, but in B.C., the brand-name pill costs $153 for a month's supply, compared with $29 to $58 for methadone, depending on the dose (not including pharmacy expenses for witnessed consumption).
The guideline came after extensive analysis of addictions research, conducted by the Canadian Research Initiative in Substance Misuse and a national review committee made up of 43 primary-care physicians, addiction medicine specialists, registered nurses and other health-care professionals. All went through conflict-of-interest screening, and the initiative received no pharmaceutical industry funding.
In 2016, 2,861 Canadians died of opioid overdose.
The guideline's strength lies in its emphasis on treating opioid use disorder in primary care, combined with its description of how different medications can play a role in treatment, said Dr. Hakique Virani, a specialist in public health and clinical addiction medicine at the University of Alberta, who was not involved in drafting the recommendations.
"Canada is fortunate, I think, to have the best reference document that exists on treating these conditions," he said.
But the guideline will only reduce opioid-related deaths if health-care providers become willing to treat opioid use disorder in doctors' offices and emergency rooms, rather than sending patients elsewhere, Dr. Virani said. "Pieces of paper don't save lives."