Pubdate: Thu, 06 Jul 2017
Source: Ottawa Citizen (CN ON)
Copyright: 2017 Postmedia Network Inc.
Author: Jonathan Gravel
Page: A7


Rules can make reducing harm harder than treating it, says Jonathan

There has been no lack of media coverage of the current opioid crisis
or sensational news releases from elected governments of all stripes
(including the Trump administration). 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 said 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 (CDSA).
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 (CPSO) and the Ontario College of
Pharmacists (OCP). 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 (CAMH).
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 rolls 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.
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MAP posted-by: Matt