Can opiates get addicts off opiates?

As the province increasingly turns to opioid substitution to combat illicit drug overdoses, some addiction specialists worry the strategy may leave thousands “parked” in addiction with little hope of ever finding a life free of drugs.

With opioid replacement, “we’re not treating addiction,” says addictions counsellor Sue Donaldson, founder of Pegasus Recovery Solutions in Victoria. “At best, we’re trying to manage it.”

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Opioid agonist therapy involves using long-acting opioid drugs such as methadone or Suboxone to replace other opioid drugs such as heroin or fentanyl. Because the replacement drugs act more slowly, they can prevent withdrawal symptoms for 24 to 36 hours without causing a person to get high.

Kelly Reid, Island Health’s director of mental health and substance use, says there “absolutely” has been a push to put people on Suboxone, which he calls a “medical, evidence-based approach to addictions medicine” that can help people addicted to drugs stabilize and move on with their lives.

Opioid agonist therapy has become the go-to medical response to the overdose crisis that claimed almost 1,500 lives in B.C. last year. In 1996, there were 2,800 people in B.C. enrolled in methadone maintenance. By 2009, that number had swelled to 11,033 and by 2017 the number of B.C. patients on methadone or Suboxone had doubled to 22,012. It’s predicted to double again within four years.

It isn’t cheap.

The province’s costs for 12 months in 2017/18 for drug replacement therapies — including costs of the drugs, dispensing fees, physician fees and supportive access to care — was $91.5 million.

While public health officials say the approach is needed to save lives, some challenge the notion that opioid agonist therapy is addiction treatment. Rather, they say, it should be considered a strategy that might be employed in the treatment process — not the be-all and end-all.

“There’s a real push to get people on opioid replacement therapy,” says Our Place executive director Don Evans, who worries that drug replacement is being seen as a substitute for recovery from drugs — something it is not.

“It’s not recovery. You’re not dealing with the underlying issues [of addiction],” Evans says, noting that while many people do pretty well on opioid in the short term, “in the long term they often don’t and they end up back on their drug of choice and still trying kind to supplement that with the [opioid agonist therapy].”

Donaldson agrees.

“Suboxone has a really important role to play. Those drugs have a really important role to play in all of this but I don’t think it should be considered a new treatment process or new treatment,” she says.

“They’ve been using opiate drugs to try to get people off of opiate drugs for almost 200 years now,” says Neal Berger, former executive director of Cedars at Cobble Hill.

“I understand the crisis and doing everything you can to prevent death, and I agree with that. I agree with having Naloxone available, and using drugs like Suboxone to help some people out if it means we can prevent some deaths.

“But it doesn’t really appear to be having much of an effect.”

And there some who question the approach’s long-term efficacy.

Methadone has been widely prescribed in Scotland for years in an effort to reduce heroin overdoses, but it hasn’t worked, says Neil McKeganey, as the number of overdoses has gone up.

Heroin-related deaths more than doubled in Scotland between 2013 and 2017. In 2018 a record 934 people died in Scotland as a direct result of drug overdose — 2.5 times the rate U.K.-wide.

In fact, there are areas of Scotland where there are more overdoses attributed to methadone than there are to heroin, says McKeganey, who founded the Centre for Drug Misuse Research at Glasgow University and now runs his own private research group.

“You can’t prescribe your way out of the drug problem. The answer is not to be found in adding more drugs into the equation,” he says.

“We have not seen the reduction in addict deaths, far from it. We have seen a persistent, steady, unrelenting increase in the numbers of addicts suffering fatal overdose because the pattern of drug use hasn’t reduced. It’s increased in quantity and it’s become more complicated.”

Vancouver’s Dr. Ray Baker, who practised addiction medicine for more than 30 years, says opioid replacement can be “an essential first step” for some suffering from addiction.

But there are some very real dangers when substitute drugs are doled out too freely and without rigorous followup and monitoring, he says.

“The problem that I see is that many of the people who are prescribing and delivering opioid substitution therapy aren’t familiar and trained in the other recovery-orientated types of care,” Baker says. “So people get started on it and they get left on it. And that’s not without hazard.”

Suboxone itself is addictive and its use has to be monitored — especially among people who may use other drugs like Xanax or Valium, cocaine or alcohol because it can cause impairment, unconsciousness, respiratory failure or death.

“The problem is that methadone is a potentially fatal drug and when it’s mixed with other drugs it and Suboxone can have severe drug interactions and can contribute to fatality,” Baker says. “So if you’re prescribing a drug, you have the obligation to monitor for safety, otherwise you could be contributing to the problem.”

The number of people who need long-term opioid maintenance “is a tiny, tiny percentage of the [addict] population,” he says.

“As a physician working in the addiction medicine for 30 years, I’ve treated hundreds of opioid-dependent people ... and we got extremely high rates of recovery using non-pharmacological treatment. But we don’t see that currently happening. We don’t see those approaches being used.”

What needs to be developed, Baker says, is a recovery-orientated continuum of care that might start with harm reduction, education and detox, moving into in-patient or out-patient treatment that is followed up with community and peer support, counselling, supportive workplaces or schools and, if needed, recovery housing.

If opioid substitution is to be used it should be part of a tightly monitored, comprehensive recovery plan that ultimately weans people off the substitute drug, Berger says.

“There’s a huge difference between managing addiction and managing recovery,” he says. “Do we have a health-care system or do we have a disease-management system? I kind of think we’re stuck on the wrong end of that continuum.”

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