Much has been written about the epidemic of opioid misuse, and the resulting harms. The statistics are chilling: In Canada alone, there are some 22 million opioid prescriptions written annually, and an estimated 2,000 overdose deaths.
But the numbers do not adequately capture the breadth of the carnage – the families torn apart, the financial ruin, the careers destroyed by dependence and addiction – and the fact that the fallout will continue for years, even decades to come.
Now, we are even beginning to talk about a second epidemic – the epidemic of treatment. Because, more often than not, the way we are treating opioid dependence is with opioids, namely methadone. Methadone is an agonist, meaning it can suppress cravings, but can also be addictive.
In Ontario alone, more than 50,000 people are on methadone maintenance treatment, according to a paper published in the medical journal Substance Abuse Treatment, Prevention and Policy.
The team of researchers from the Centre for Addiction and Mental Health and the University of Toronto, led by Dr. Benedikt Fischer, ask some uncomfortable, but necessary, questions about that mind-boggling number. In particular: Is the way we treat opioid addiction actually perpetuating the problem?
It needs to be said up front that the authors are not opposed to methadone maintenance treatment. On the contrary, most have, over the years, actively argued for its broader availability.
However, in the paper, they express the concern that methadone is now being misused and overused. The problem is that methadone has become the first-line treatment: A drug that is supposed to be used as a harm-reduction tool for serious addicts is now being prescribed to people whose opioid misuse is not particularly risky or intense. (And, while opioid misuse is worrisome, we have to be careful not to be gripped by Reefer Madness-like hysteria.)
One of the most troubling facts in that paper is that, in some health regions, one in five people on methadone maintenance treatment are under the age of 25.
Methadone is a long-term (minimum a year) – and often, life-long – treatment. While it has unquestionable therapeutic benefits for people who are opioid dependent, it is still associated with the adverse effects of the drug, such as much higher rates of depression and mortality.
Ontario had 3,000 methadone patients in 1996, 29,000 in 2010, and about 55,000 today. Per capita, Ontario's rate of prescribing is about four times the U.S. rate, where the opioid epidemic is as bad, if not worse.
The CAMH researchers note that it is not coincidental that the province has introduced incentives that, in the past few years, have led to the proliferation of for-profit methadone clinics. Ontario Addiction Treatment Centres alone has 57 clinics in Ontario (and one in Manitoba), not to mention numerous pharmacies that have patients come in to swig a daily dose of liquid methadone with orange juice.
(Methadone clinics are also an issue in the ongoing contract dispute between Ontario and its physicians, because a number of the province's highest-billing doctors are methadone providers, who make a lucrative living not only from dispensing the drug, but also from the frequent urine tests that are required.)
Methadone treatment costs the Ontario health system an estimated $250-million a year.
Some of that spending is justified but what the researchers argue for is a "stepped care" approach to treating those with opioid dependence. In other words, start with non-pharmaceutical interventions such as psychotherapy (cognitive behaviour therapy, in particular), detox and other approaches that allow users to taper off the drugs before turning to methadone.
Sadly, there has been too little research and investment in these non-drug alternatives. We are always looking for a magic pill.
There is also a push by many to make more judicious use of Suboxone (a combination of buprenorphine and naloxone), which is an agonist, meaning it blocks cravings but it far less likely to be addictive than methadone.
The take-home message here is that harm-reduction tools like methadone are important, but they have to be used appropriately.
Indiscriminate prescribing is the root cause of the opioid epidemic. The solution is not indiscriminate prescribing of an opioid-based treatment that, in many ways, perpetuates the problem.