Starting this month, the College of Physicians and Surgeons of BC lifted a regulation barrier that will improve access to Suboxone, a drug that is used to treat opioid addiction.
Opioids are a class of drugs that include heroin, fentanyl and morphine. While many opioids are often prescribed as powerful painkillers, they can also induce tolerance and dependence and lead to addiction. Over the past few years, while the number of prescriptions for opioids have been going up in BC, so have the rate of overdoses.
Currently, the two main treatments for opioid dependence in BC are methadone and Suboxone, a combination of two separate drugs: buprenorphine and naloxone. Until now, doctors looking to prescribe either of these drugs needed to complete a course to obtain a methadone license. However, recent reports detailing the improved safety and efficacy of Suboxone compared to methadone have called for the lifting of this restriction.
“We know from a lot of the literature that Suboxone is a much safer medication compared to methadone. It’s got a safety profile that boasts six times safer when compared to methadone,” said Seonaid Nolan, a clinical scientist at the BC Centre for Excellence in HIV/AIDS and one of the co-authors of a report released in May calling for improved access to opioid addiction therapies. “There's not really a lot of rationale as to why an individual would have to hold a methadone license to prescribe Suboxone.”
This regulation change will improve access for Suboxone, particularly in parts of BC where there are fewer physicians and addiction treatments available.
Methadone and Suboxone are examples of substitution treatments — drugs used to treat opioid dependence that are in the same family as other opiates. Compared to heroin, which can produce withdrawal symptoms four hours after a dose, methadone is a much longer acting drug that produces less of a euphoric “high” but controls withdrawal symptoms for up to a day.
The problem is that patients still need to be weaned off of methadone.
“It’s a really difficult long withdrawal that can take some people a year. It's a many-month-long, difficult, painful withdrawal,” said Mark Haden, adjunct professor in the School of Population and Public Health. “It's harder to withdraw from methadone than it is from heroin.”
Suboxone offers a few advantages: it is easier for patients to withdraw from than methadone, it has been documented to produce fewer overdoses and there is a lesser risk of drug diversion, or being resold on the street. Unlike methadone it has a “ceiling effect,” where it does not create as much sedation and drowsiness as the dose is increased, reducing the risk of overdose. It also contains naloxone as one of its ingredients, a drug that blocks the effects of opioids. When taken under the tongue as prescribed, naloxone is not well absorbed into the body and does not produce much of an effect. This changes when attempts are made to tamper with the drug administration.
“If Suboxone is used in a way that it's not prescribed — so crushing it, injecting it — the naloxone component becomes active, and it causes what we call precipitated withdrawal,” said Nolan. “It makes someone very uncomfortable.”
According to Michael Krausz, a UBC professor specializing in addictions psychology, the regulation change is a good step forward, but it is just one of many that need to happen, including creating greater access to safe injection sites and continuing to increase access to a greater range of substitution therapies in addition to just methadone and Suboxone.
“There is not a golden bullet for treatment of opioid dependence,” said Krausz. “As in the treatment of pain or depression or arthritis or infection, it's important to have several options.”
Recent studies support the use of opiates such as hydromorphone and even heroin for the treatment of heroin addiction. Between 2005-2008, the North American Opiate Medication Initiative trials demonstrated that using pharmaceutical quality heroin in a controlled setting was more effective in treating addiction in the hardest to treat populations than methadone. Following this, the Study to Assess Longer-term Opioid Effectiveness, which wrapped up earlier this year, found that hydromorphone worked just as well as heroin for difficult-to-treat addicts.
“I think that all physicians should have a range of different opiates … and they should be [available for] both intravenous and oral use,” said Haden. “People should be able to access different opiates in different contexts — again, with supervision and a medical reside and consultation — but the process is a thoughtful, evidence-based process.”