Don't treat heroin and opioid addiction as short-term conditions: paper

VANCOUVER – Addiction to heroin and other opioids is a long-term, chronic disease that can’t simply be fixed with a few weeks or months on methadone, a group of British Columbia-based researchers argue in a newly released paper.

Designing treatment based on the belief that most addicts can become drug-free quickly — or even at all — is ineffective and dangerous, the report warns.

The paper, published in the August edition of the journal Health Affairs, says research has repeatedly shown detoxification programs that use short-term bouts of methadone or similar therapies, reducing dosages over a period of weeks or months, are ineffective, with as many as 95 per cent of patients who complete such programs failing to stay clean.

One of the paper’s authors, Bohdan Nosyk of the B.C. Centre for Excellence in HIV/AIDS, said treatment programs that focus on abstinence as the end goal represent “the most damaging” aspect of opioid treatment in North America.

“This is a chronic disease, something that is going to have to be fought day by day over a long period — potentially a lifetime,” Nosyk said in an interview Tuesday.

“That’s difficult for people to accept. I still think there’s a demand that they want this problem dealt with quickly.”

Nosyk said public health policies in Canada generally acknowledge that reality, but, in practice, some physicians and patients still hold onto the notion that treatment with methadone or its lesser-known counterpart, buprenorphine, should be a temporary stop on the way to abstinence.

The situation is worse in the United States, said Nosyk, where detoxification is an essential part of official drug-treatment policy.

“It’s a matter of recognizing this as an issue that’s likely not going to go away and using the tools that we have to combat it in the best possible way,” said Nosyk.

Aside from being ineffective, detox-oriented treatment can also be dangerous, said Nosyk. The risk of death for someone seeking treatment for opioid addiction is highest during the first two weeks of treatment and the two weeks immediately after they stop, he said.

The paper examined the availability of methadone and buprenorphine, which are themselves opioids, in Canada and the United States. Methadone and buprenorphine are used as substitutes for addictive opioids to reduce cravings and eliminate withdrawal symptoms, without getting patients high.

There are between 75,000 and 125,000 injection drug users in Canada, with most of them using opioids such as heroin, as well as roughly 200,000 people addicted to prescription opioids, such as oxycodone.

Of those, between 30 to 40 per cent are using substitution therapy, said Nosyk. In the United States, where an estimated 2.3 million people are hooked on opioids, treatment levels are less then 10 per cent.

The paper identifies several barriers to methadone and buprenorphine treatment across Canada, including waiting lists of up to a year in places such as Saskatchewan and Montreal, financial costs such as insurance co-payments, and the stigma of having to access the therapies at community drug clinics or pharmacies.

The researchers make a number of recommendations, including changing the way patients pay for methadone and buprenorphine.

Nosyk said the therapies are typically handled by provincial health-care systems and insurers in the same way as any other prescription drug, with patients responsible for deductibles or co-payments unless they qualify for low-income drug coverage.

He said policy-makers could learn from B.C.’s approach to HIV/AIDS treatment.

The province provides treatment free of charge to every patient with HIV or AIDS, based on research that has shown widespread treatment is the best form of prevention. The result has been a consistent decline in new HIV cases in B.C. — something that hasn’t happened in any other province.

Nosyk said a similar approach would improve opioid addiction treatment, which, in turn, would save the health-care system money, as well as reduce crime associated with drug addiction.

“People are dying of overdoses, and we know if we get them on treatment, there are going to be benefits in other areas of society,” said Nosyk.

“We have reason to believe that offering treatment saves the economy money.”

The paper also calls for provinces to expand treatment into doctors’ offices.

In Canada, methadone and buprenorphine are primarily administered at community-based pharmacies, where patients must take their therapy under the watch of a pharmacist. Patients who are stable and who are considered a low risk for abuse are allowed to take the medication home.

Doctors who have obtained special certification can administer the treatment in their offices, but Nosyk said very few doctors outside of Vancouver and Toronto have such certification.

“On the whole, we’re doing much better (than in the United States), but getting physicians to get their exemptions to prescribe methadone and buprenorphine, particularly in rural regions, hasn’t been easy,” said Nosyk.

“There are regions across Canada where treatment is limited and not a lot of physicians have taken the opportunity to get their exemptions. It’s easy to get,” he added, noting the certification can be obtained through a weekend-long course.

One way to increase treatment in doctors’ offices would be to include drug-addiction therapy in medical school curricula, said Nosyk.