- Open Access
Too much or never enough: a response to Treatment of opioid disorders in Canada: looking at the ‘other epidemic’
© The Author(s). 2016
- Received: 18 April 2016
- Accepted: 8 September 2016
- Published: 20 September 2016
Prescription opioid (PO) misuse is a major health concern across North America, and it is the primary cause of preventable death for the 18–35 year old demographic. Medication assisted therapy including methadone and buprenorphine, is the standard of care for patients with opioid-dependence. Moreover, both of these medications are recognized as essential medicines by World Health Organization. In Ontario Canada, the availability of medication assisted therapy has expanded substantially, with almost a ten-fold increase number of patients accessing methadone in Ontario in the past decade. In their manuscript, Fischer et. al. (2016), present a view that expansion of opioid maintenance therapy (OMT) has outpaced true patient need and alternate strategies should be considered as first-line treatments. Here, we present a countering perspective-that medication assisted therapy, along with other harm reduction strategies, should be widely available to all opioid-dependent people as first-line treatments.
Prescription opioid (PO) misuse is a major health concern across North America. Fueled by liberal PO prescribing during the late 1990’s and 2000’s, Ontario is often cited as a region suffering from a public health crisis due to PO-dependence [7, 11, 14]. Today, opioid-related overdose is the number one cause of death for 18–35 year olds in Ontario , and this trend holds true for Canada and the US . Sadly, opioid-overdose deaths are far more likely to occur following abstinence-based treatment programs; and the reason is all too often relapse during a time of increased opioid sensitivity which follows detox . In an effort to address the PO epidemic, some provinces in Canada have dramatically expanded access to medication assisted therapy, including the province of Ontario.
The evidence to support the efficacy of medication assisted treatment (e.g., methadone and buprenorphine) is well established for heroin-using patients , and due to the pharmacological similarities of prescription opioids (including oxycodone) methadone and buprenorphine have demonstrated efficacy for prescription opioid users as well . However, Fisher et. al., (2016) also question the generalizability of studies conducted in a heroin-using population to the prescription opioid-dependent population.
Recently, the question has been raised, when is there too much medication assisted therapy? Fischer et. al., (2016) present a view that expansion of opioid maintenance therapy (OMT) has outpaced true patient need for treatment in the province of Ontario, Canada. Further, the authors imply that economic incentives surrounding delivery of methadone have ‘unduly influenced the expansion of OMT in Ontario’. Finally, the authors argue towards a continuum-of-care which focuses on alternatives to maintenance therapy citing taper, detox and abstinence-based approaches as alternatives for a subset of prescription-opioid dependent patients. Here, we argue against the position that OMT capacity has expanded beyond need; and we believe that significant need still exists, especially in Northern and rural regions of the province [9, 13].
We support the Fisher et. al., (2016) recommendation that there is a need for more high quality epidemiological surveillance data to quantify and inform resource allocation towards treatment of opioid-dependence. However, we strongly oppose the implication that OMT programming is sufficiently serviced in the province of Ontario, especially in northern and rural regions. Moreover, the absence of robust data, which Fisher et. al., (2016) assert is lacking for other treatment options, is not a reason to reduce the availability of our most effective treatment at a time when people are dying from a public health crisis. It is our opinion that more resources should be allocated towards understanding and developing comprehensive care models which improve the overall health outcomes of this complex patient population - including expanded opioid maintenance treatment programming, especially in rural and remote regions of the country.
The primary author (JKE) received funding as a successful recipient of the 2014–2015 CANOC Scholarship Awards Programme; (this programme is supported through the Centres Grant [CIHR 711314]).
JKE, KMT, and DCM conceived of and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.
DCM is the Deputy Dean of the Northern Ontario School of Medicine and the Medical Director for the Canadian Addiction Treatment Centers.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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