Reducing the Harm Associated with Injection Drug Use in Canada
Appendix B - National And International Experiences
Drug Treatment and Rehabilitation in Canada
Most drug treatment and rehabilitation programs and services in Canada fall under provincial/territorial jurisdiction. The federal government collaborates with the provinces and territories to stimulate the development of innovative treatment and rehabilitation programs, evaluate programs, identify best practices, and disseminate information across the country. Health Canada also manages the Alcohol and Drug Treatment and Rehabilitation Program, through which provinces and territories access funding to improve accessibility to effective programs and services.
Treatment and rehabilitation services in Canada include the following: detoxification services, early identification and intervention, assessment and referral, basic counseling and case management, therapeutic intervention, and aftercare and clinical follow-up. Treatment is offered on an out-patient, day-patient, or in-patient basis, including short-term and long-term residential care. Specific treatment and rehabilitation programs have been developed to address the unique needs of certain target groups of the population, such as women, youth, Aboriginal peoples, driving-while-impaired offenders, and inmates in correctional facilities. Provisions exist in current drug legislation to encourage alternatives to incarceration, such as treatment and rehabilitation, in appropriate circumstances.
Treatment and rehabilitation in Canada has evolved significantly over the past several decades.161 Prior to the 1950s, treatment tended to be dominated by moralistic attitudes, and most people had little access to treatment, since the predominant view was that these people lacked will power or had personality defects. In the 1950s and 1960s, it was felt that alcoholism, specifically, was a preventable and treatable "disease" rather than a symptom of moral weakness, and 12-step recovery programs became popular. By the end of the 1950s, most provinces and territories had established departments, commissions, or foundations to provide or coordinate addictions treatment, and many new services were made available. As problems with drugs other than alcohol began to increase, these agencies began to expand their mandates to address these emerging issues. The mid 1960s was characterized by a rapid expansion of addictions services. Compulsory treatment for people addicted to heroin was tried in British Columbia, but it ran into a number of problems related to civil rights and public perception.162 In the 1980s, provincial/territorial agencies became relatively autonomous within their respective health and social service systems, services became more diverse and specialized to meet the needs of various target groups, and a number of treatments based on cognitive, behavioural, and social theories emerged.
Methadone Maintenance Treatment
Internationally, methadone maintenance treatment continues to be the gold standard and most commonly used treatment strategy for opiate dependency. It has been shown to improve health status, increase employment, improve pregnancy outcomes, decrease opioid use, the use of other drugs, crime and incarceration, and have a positive economic effect on society. It has been shown to prevent transmission of blood borne pathogens. One study found that after four years, those who had received no treatment were 4.2 times more likely to have seroconverted to HIV positive than those who had received two or more years of methadone treatment.163
Methadone has advantages in that it can be taken by mouth, has a slow onset of action, does not result in continuing tolerance, permits a relatively constant dose over time, does not cause euphoric or sedating effects, is long acting, blocks the euphoric effects of heroin, and is medically safe when appropriately prescribed and dispensed, even when used on a long term basis.
Research from the United States indicates that criminal activities related to heroin use result in social costs that are four times higher than the cost of methadone maintenance treatment. There is a saving to the community of between US$4-$13 for every dollar spent on methadone maintenance treatment.164 In Toronto, the average social cost of an untreated illicit opioid user has recently been estimated to be $49,000 per year.165 Methadone maintenance treatment can be provided for approximately $6,000 per year.
Australia, the UK, Switzerland, the Netherlands and Germany, have expanded methadone maintenance treatment over the past decade. It has been closely linked to other essential services for people who inject drugs such as needle exchange, outreach services, education programs, counseling and injection drug user networks.
In Canada, the Office of Controlled Substances within Health Canada controls the sale and manufacture of methadone. To prescribe methadone, physicians must receive an exemption under the Controlled Drugs and Substances Act. During consultations, health professionals, licensing bodies and methadone clients expressed the need to increase accessibility to effective methadone maintenance treatment in Canada. In Canada there are 699 physicians authorized to prescribe methadone for narcotic dependence. Stakeholders have indicated that this number is not adequate to satisfy the demand.
Provinces are beginning to take over some responsibilities for administering methadone maintenance treatment but, at this time, the provinces are at different stages of development and implementation in this area. British Columbia has taken the lead in the administration of methadone, and has developed guidelines and training programs for physicians. Ontario and Quebec have also developed guidelines and training for physicians.
Other provinces, including Alberta, Saskatchewan, Manitoba and Nova Scotia are in the process of developing guidelines and/or training programs for service providers. Some provinces charge user fees for methadone maintenance treatment.
In Canada, methadone maintenance treatment is provided primarily in community-based clinics, increasingly in physician's offices, in federal correctional facilities, and in some provincial correctional settings.
Many physicians are reluctant to prescribe methadone for opiate dependency because of issues such as stigma, lack of experience in the field of addiction, and in rural communities, the feeling of being isolated from other essential services.
Methadone maintenance treatment is available in federal correctional facilities in Canada if the inmate was in a methadone treatment program prior to incarceration. The first phase of the Methadone Maintenance Treatment program in federal correctional facilities was modified in March 1999 to allow, in "Exceptional Circumstances", the option of providing methadone maintenance treatment if the inmate has attempted all available treatment and programs and has failed; the health of the offender continues to be seriously compromised by addiction; and there is dire need for immediate intervention. British Columbia, Ontario, Nova Scotia, Saskatchewan, Manitoba, and Quebec offer methadone maintenance treatment programs in prison where it is the continuation of participation in a community based program.
Alternative Pharmacotherapies
In 1997, countries reported to the United Nations regarding the existence of narcotic maintenance programs for people addicted to heroin.166 Switzerland and the United Kingdom reported use of buprenorphine, Germany and Switzerland reported use of codeine, Germany reported use of dihydrocodeine, Portugal reported use of LAAM, Guatemala, Mexico and Switzerland reported use of morphine, and Guatemala reported use of pethidine. Since then, the United States approved both naltrexone and LAAM as treatment options. France has approved the use of buprenorphine, and it is expected that Australia will add buprenorphine to its list of treatment options.
In the United States, substantial research has been conducted on the use of LAAM for the treatment of opiate dependency. Treatment with LAAM was found to be comparable to methadone maintenance treatment in relation to reduction of illicit opiate use, treatment retention, employment, and involvement in illegal activities and arrests.167 LAAM has a slow onset and long duration of action, requiring the patient to visit the clinic only every two or three days. Methadone requires daily visits by the client in the early stages of treatment. It is not necessary for patients to take LAAM away from the clinical setting, averting the risk of diversion to illicit markets. LAAM appears to be most effective with patients who require fewer clinic visits. However, it is considered to be less effective for those who would benefit from more intense care and supervision provided by daily visits.
There have been very few reports of toxicity; toxicity reports are generally associated with multiple drug use. Risk of overdose is high when LAAM is taken in conjunction with alcohol, sedatives, tranquilizers, antidepressants, and benzodiazepines. LAAM must be prescribed with caution to patients with hepatic or respiratory diseases or cardiac conduction defects.
Several trials of buprenorphine have demonstrated its efficacy in treating opiate-dependent patients.168 Buprenorphine reduces heroin use, blocks subjective and physiological effects of other opiates, and augments treatment retention. It can be withdrawn or tapered off with relative ease. However, buprenorphine is subject to misuse. Combining buprenorphine with naloxone reduces this problem. Although buprenorphine is not available on the Canadian market, it can be accessed by physicians through Health Canada's Special Access Program under the Food and Drug Regulations, provided that the company which produces it is willing to provide it.
There is no cocaine substitution treatment available in Canada.
Heroin Prescription
In some countries with highly developed systems for methadone maintenance treatment, a substantial proportion of heroin users, nonetheless, remain resistant or refractory to this mode of treatment. These individuals tend to be long-term heroin users, have experienced several failures with methadone maintenance treatment, and are often currently diagnosed with psychiatric illnesses.
To assist these individuals, the United Kingdom, which has had a long history of heroin maintenance,169 uses this form of treatment for approximately 1.5% of the people who are addicted to heroin. The Swiss government initiated trials of medically prescribed heroin for treatment resistant heroin addicts in the early 1990s.170 The trial found a net economic benefit of US$30 per client per day, largely due to reduced criminal justice and health care costs. The success of these trials and the result of a referendum convinced the Swiss government to commit to heroin treatment as part of its treatment continuum for persons who have failed other treatment.
The Netherlands undertook a scientifically rigorous trial of heroin treatment, and other countries (e.g. Germany, Spain) are planning initiatives of their own. A North American scientific consortium - the North American Opiate Medication Initiative (NAOMI) is developing a clinical trial proposal.
It is important to note that, even in countries that are testing and using heroin as a treatment option for a select population, methadone maintenance treatment continues to be the best option and gold standard course of treatment for the majority of clients.
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