Safer solution in sight

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This article was published 08/08/2016 (3432 days ago), so information in it may no longer be current.

Addiction expert Dr. Adrian Hynes says there’s a straightforward solution to helping the rising tide of opioid addicts in Manitoba: prescribe them the best cessation drug available.

Yet the medical director of concurrent disorders at the PsychHealth Centre at Health Sciences Centre says thousands of addicts in the province are going without treatment, because of restrictive rules regarding prescribing a drug routinely used in the U.S. and Europe.

“I don’t think any addiction expert doubts Suboxone is safer than methadone,” he says of the cessation drug that has been available in Canada for about a decade.

“Yet Pharmacare has made it difficult to prescribe, and we don’t have enough prescribers because the College (of Physicians and Surgeons of Manitoba) has put up inappropriate barriers.”

Suboxone — whose primary agent is buprenorphine — is as effective as methadone, and it is generally considered safer because risk of overdose is lower.

It also requires less physician oversight. For these reasons, Suboxone could be a key tool in treating increasing dependency to opioids in Manitoba, Hynes says.

According to estimates, about two per cent of the population suffers from addiction to synthetic opiates — referred to as opioids — that include Percocet, Oxycontin and fentanyl.

“In Winnipeg alone, that’s about the population of Portage la Prairie,” Hynes says.

Treatment is effective, but it generally must include opioid-replacement therapy, involving medications like methadone and Suboxone, to manage withdrawal symptoms and, more importantly, the often incessant cravings.

“With alcohol, you get treatment to learn to manage your craving, and a year later that craving has gone down significantly so you don’t have a preoccupation with the substance 24/7,” says Hynes.

Addiction to cocaine, marijuana and other drugs responds similarly to treatment — the craving decreases over time — but opioids are different.

“If you have a significant addiction to the opioids, the craving is still pretty close to (the) starting point five years later,” he says.

That makes it difficult to quit without using medication. The first-choice drug is methadone, which has been available for decades, and it is covered by Pharmacare. Despite its safer profile, “Suboxone is only available on exception drug status, which means I have to write a letter to justify it because of failure of methadone,” Hynes says.

Responding to a request from the Free Press, Manitoba Health states in an email that it is reviewing Suboxone’s status.

“However, in patients with a history of long-term, high-dose, potent opioid use and with a high tolerance, methadone treatment still performs better in long-term treatment when compared to Suboxone,” Manitoba Health states in the email.

Yet Hynes argues prescribing Suboxone should be easier, allowing more patients to access it, as its lower risk profile requires less supervision than a methadone program. This would have the benefit of increasing the number of addicts receiving out-patient treatment, the standard for opioid-addiction care.

He estimates just a fraction of people with dependency can be treated in maintenance programs in Manitoba (about 500), because only a handful of doctors are qualified to prescribe either cessation drug.

More physicians — including family doctors — could be trained to treat patients with Suboxone, but current rules regarding training, set by the College of Physician and Surgeons, are too restrictive.

“Suboxone has been married to methadone” with regard to training requirements even though it doesn’t need to be, he says.

Doctors must spend four half-days of in-clinic education to prescribe methadone or Suboxone, but Hynes and his colleague at HSC, psychiatrist Dr. Josh Nepon, have been lobbying the college to reduce the amount of time required for Suboxone training.

“For many family docs, four half-days is too many to take off from their practice,” Hynes says.

Alternatively, doctors could take a one-day online course to learn how to prescribe Suboxone safely.

“As far as I’m concerned, they’re then competent to prescribe it, as long as they have a telephone number to call if they run into trouble,” he says. (Both Hynes and Nepon have volunteered to be the physicians on call should the rules change.)

Dr. Marina Reinecke, the lead opioids expert for the college, says the regulatory organization for physicians in the province is engaged in a number of initiatives aimed at opioid addiction, including increasing training for prescribing methadone and Suboxone.

Moreover, she says many physicians completing the current training indicate it is helpful.

“Many physicians ask for more clinic training time after the four half-days, not less,” says Reinecke, who acts as a mentor for physicians after they complete the course.

Still, the college is reviewing training and rules for prescribing Suboxone.

“We continue to monitor and find new avenues to reach out to our members regarding prescribing practices when it comes to drug abuse and addictions.”

Yet Hynes says his concerns have fallen on deaf ears so far with both the province and the college. And in the meantime, he adds, opioid addicts struggle to get treatment, continuing to use drugs while putting themselves at risk of accidentally overdosing on high-potency opioids such as fentanyl.

While not a panacea, Suboxone is effective and about half as likely to result in death, according to one study, Hynes says.

But because rules for prescribing it are subject to a double standard — whereby physicians can responsibly prescribe opioid painkillers without the same level of training required to prescribe the drugs to treat the dependency opioids can cause — patients are often going without the best care available, he says.

“If Suboxone was a cancer drug and it was twice as effective as the next best cancer drug, how long do you think there would be an outcry over it not being covered by Pharmacare?”