Expanding medical treatment options for opioid addiction
Reprinted from "Opioids" issue of Visions Journal, 2018, 13 (3), p. 35
Every day in Canada, 16 people are hospitalized as a result of an overdose. Seven people in the country will die. That’s every single day. More than 3,000 deaths due to overdose are anticipated in Canada in 2017 alone.
Here in British Columbia, the staggering increase in the number of overdoses led to the province declaring a public health emergency in the spring of 2016. Despite the efforts of first responders, health care providers and peer groups working tirelessly to respond to overdoses when they happen, fatal overdoses continue in the province at an unfathomable rate. More than 1,000 people have died in the year and a half since the public health emergency was declared.
The introduction of fentanyl and other powerful opioids into the drug supply has been a major contributing factor to the overdose emergency. The death toll also exposes a reality that addiction medicine specialists, families affected by addiction and people who use drugs have known for some time: the system of care for substance use is ill-equipped to properly identify, treat and care for those with problematic substance use.
Opioid addiction is a major driver of the recent surge in overdose deaths in the province. It’s also one of the most challenging forms of addiction facing the health care system in BC. Addiction may involve the use of illicitly manufactured opioids, such as heroin or street fentanyl, or prescription opioid medications obtained illicitly. We don’t have current estimates for opioid addiction rates among Canadians, but opioid addiction affects approximately 2.1% of Americans.1
Earlier this year, the team at the BC Centre on Substance Use (BCCSU) released guidelines to support physicians, nurse practitioners, nurses, allied health professionals and other care providers involved in the treatment of individuals with opioid addiction. The new guidelines address both the lack of awareness among care providers and the under-utilization of alternative treatment options. Developed in consultation with key health systems partners, community and family advocacy groups and international experts, the guidelines reflect the best available evidence and are informed by the lived experiences of people who use drugs and the families of people who use drugs. They also make recommendations for best treatment.
The new guidelines recommend buprenorphine/naloxone, which has a brand name of Suboxone®, as the first-line treatment for opioid addiction. It’s safer than methadone, with a lower likelihood of fatal overdose, a lower risk of adverse events and fewer side effects and interactions with other drugs. Treatment also requires fewer clinical visits and, in many cases, is more flexible when it comes to take-home dosing.
For many years, methadone has been the most commonly prescribed treatment for opioid addiction in Canada. Studies have shown it to be significantly more effective than withdrawal or other non-pharmacological outpatient treatments, both in terms of retaining patients in treatment and suppressing opioid use.
However, there are regulatory challenges and potential negative individual and public health effects associated with methadone. Patients on methadone must visit their doctors frequently to receive their medication; most patients have to take their medication daily at a pharmacy, witnessed by a pharmacist. This can make accessing treatment difficult for some. The potential for interactions with alcohol and other substances increases the relative risk of toxicity. There is also an increased risk of medication being diverted to the illicit drug market, where methadone is bought and sold illegally. Recent reports have also highlighted the low number of methadone prescribers in British Columbia, particularly in rural regions, as well as the program’s poor retention rates.
Another treatment option recommended in the BCCSU guidelines for patients who have not benefited from either buprenorphine/naloxone or methadone is slow-release oral morphine. Kadian®, a slow-release 24-hour formulation, is approved in Canada for pain management; there is growing evidence to support its use in the treatment of opioid addiction.
Other treatment options
Unfortunately, these medications don’t work for everyone. Side effects, intolerance, cravings and ongoing drug-related harms may mean that some individuals require other treatment options. Without treatment alternatives, these individuals face significant risks, including fatal overdose, due in large part to the unpredictable presence of fentanyl and other opioids in the illicit drug supply.
That’s why the BCCSU guidelines also include recommendations for non-oral treatment, called injectable opioid agonist treatment. This treatment includes injectable hydromorphone and prescription heroin—and it is controversial. But the guidelines are grounded in extensive international and Canadian research, including the North American Opiate Medication Initiative (NAOMI)2 and the Study to Assess Long-term Opioid Maintenance Effectiveness (SALOME),3 studies conducted at Providence Health Care’s Crosstown Clinic in Vancouver. These studies show that hydromorphone and prescription heroin are both effective treatments for opioid addiction and can provide social stability and health benefits to those who have not benefited from other oral treatments.
In addition to these pharmaceutical treatments, evidence-based psychosocial interventions and supports, including counselling and programs that focus on individual circumstances like housing and employment needs, are also recommended to support recovery from opioid addiction. And it’s important to strengthen the residential treatment system with a view to aiding individuals seeking long-term recovery from opioid addiction.
Care providers and patients need to have as many treatment options available to them as possible. Expanding access to treatments is critical to addressing the opioid overdose crisis and will aid the development of an addiction system of care for all British Columbians affected by substance use and addiction.
About the authors
Cheyenne is Director of Clinical Activities and Development at the BC Centre on Substance Use (BCCSU), a provincially networked organization with a mandate to develop, help implement and evaluate evidence-based approaches to substance use and addiction. She completed her bachelor of nursing science at Queen’s University and her graduate degree at Simon Fraser University
Emily is Senior Medical Writer at the BCCSU. She completed her undergraduate and graduate degrees at Simon Fraser University. Prior to joining the BCCSU team, she worked and volunteered at a number of non-profit organizations in the areas of mental health, HIV/AIDS and women’s health
Grant, B.F., Saha, T.D., Ruan, W.J., Goldstein, R.B., Chou, S.P., Jung, J., Zhang, H., Smith, S.M., Pickering, R.P., Huang, B. & Hasin, D.S. (2016). Epidemiology of DSM-5 Drug Use Disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. JAMA Psychiatry, 73(1), 39-47.
Oviedo-Joekes, E., Nosyk, B., Brissette, S., Chettiar, J., Schneeberger, P., Marsh, D.C., Frausz, M., Anis, A. & Schechter, M.T. (2008). The North American Opiate Medication Initiative (NAOMI): Profile of participants in North America’s first trial of heroin-assisted treatment. Journal of Urban Health, 85(6), 812-825.
Oviedo-Joekes, E., Marchand, K., Lock, K., MacDonald, S., Guh, D. & Schechter, M.T. (2015). The SALOME study: Recruitment experiences in a clinical trial offering injectable diacetylmorphine and hydromorphone for opioid dependency. Substance Abuse Treatment Prevention Policy, 10(1), 3. doi: 10.1186/1747-597X-10-3.