There’s a madness to our methadone regime

There has been no lack of media coverage of the opioid crisis or sensational press releases from elected governments of all stripes. We have debated the root causes, the mistakes along the way and the solutions, into the ground.

Licit opioids — those prescribed by physicians for pain — are a mainstay in the relatively small arsenal of pharmacological analgesics available to us. As a newly minted resident physician with a few more letters at the end of my name, I am free to prescribe opioids as I, with oversight from a staff physician, see fit; and in two quick years, I can do it without oversight. And I will, because treating pain is important.

But what if I want to prescribe methadone maintenance treatment (MMT), which is a recognized and relatively effective treatment for opioid dependence? Methadone, a long-acting opioid with limited euphoric effect, which has been prescribed and studied for decades, works by reducing the awful physical withdrawal symptoms and drug cravings experienced as one comes off either licit opioids or heroin.

But to do so, I need to apply through Health Canada for an exemption under Section 56 of the Controlled Drugs and Substances Act. Prescribing any other opioid, including much stronger and much more addictive types, has no such requirement.

Regardless, it sounds relatively straightforward, right?

Not so fast. Methadone is regulated by Health Canada in partnership with Ontario’s Ministry of Health and Long-Term Care, the College of Physicians and Surgeons of Ontario and the Ontario College of Pharmacists.

So, before even being considered for the exemption, I must first complete the Opioid Dependence Treatment Certificate Program through the Centre for Addiction and Mental Health. This includes four or five very informative and fascinating courses that are not only time-consuming but expensive (the requirement was only one course until 2009).

Then, one must shadow a methadone prescriber for two days.

This is no small barrier to increasingly financially burdened medical residents or busy practising physicians.

Yes, methadone carries risk. Possible illegal diversion and overdose is essentially the argument for the aforementioned application process. But this no different from, say, Tylenol 3, or the long list of licit opioids that are prescribed every day across the spectrum of medical specialties.

Furthermore, the patients seeking the former are often doing so because they have become dependent on the latter. Plus, should we not be more concerned about the patients not seeking treatment for their opioid dependence than those that are?

It is important to note that in Ontario and several other provinces, buprenorphine and buprenorphine/ naloxone combinations, a newer, potentially safer, alternative to methadone, do not require jumping through any of these hoops.

Nonetheless, there are already significant issues in attracting physicians to work in addictions — including, but not limited to, fear of a transient and difficult patient population and stigma.

As the opioid crisis roles on seemingly unabated, the need for this exemption does nothing other than worsen access to addiction and harm-reduction services for an already vulnerable and often disenfranchised patient population.

As a profession, we are moving slowly but surely away from the paradigm of “doing no harm” to “harm reduction.” This barrier, a relic of a time long past, should be removed as soon as bureaucratically possible because reducing harm must become easier than causing it. Jonathan Gravel is an epidemiologist and a family medicine resident physician at the University of Toronto.