In Canada, Lifesaving Methadone Is Available in a Variety of Treatment Settings

Overview

Methadone is an effective medication, approved by the Food and Drug Administration, to treat opioid use disorder (OUD). Research shows that it can reduce overdose deaths and help people stay in treatment.¹ In the U.S., the medication is heavily regulated and available only at opioid treatment programs, health care facilities governed by federal and state laws. These programs subject patients to punitive rules—such as limits on takehome doses and frequent urine screens—born of stigma surrounding addiction and the medication itself.²

Other countries approach methadone treatment differently, often making it easier for patients to access lifesaving care while still fulfilling obligations under international drug control treaties.³ These international approaches can shed light on ways for policymakers to improve OUD treatment in the U.S.

Canada’s approach to methadone treatment

Like the United States, Canada is experiencing an opioid overdose crisis.⁴ However, across the border, people are more likely to access lifesaving care. In fact, a 2017 study in Vancouver found that 70% to 85% of people with OUD were linked to addiction care, and most people received methadone or buprenorphine, another effective medication.⁵ In contrast, the study authors note that in the U.S., just 20% to 40% of people with OUD are estimated to receive any addiction treatment in a given year.⁶

This stark difference may be attributed, in part, to Canada’s less restrictive methadone delivery model. It allows health care providers who complete trainings, if required by their province, to prescribe methadone to any patient under their care in need of the medication.⁷ Methadone prescriptions can then be dispensed at retail or community pharmacies.⁸

Treatment settings and guidance

The Canadian federal government issues national guidelines related to the clinical management of OUD— including effective medications to treat the condition and considerations for pregnant people—and updated recommendations for continued treatment of OUD during the COVID-19 pandemic.⁹

Beyond these guidelines, methadone regulation in Canada is primarily delegated to the provinces, which establish rules about who can prescribe the medication, eligibility for take-home doses, and other aspects of service delivery.¹⁰

Although this approach has led to great variation in the delivery of methadone within Canada, the treatment can be delivered in six settings throughout the country, including:¹¹

1. Provincially funded addiction clinics.
2. Outpatient physician offices.
3. Federal and provincial correctional facilities.
4. Pharmacies.
5. Residences via take-home doses.
6. Hospitals.

Health care providers in Canada—including physicians and nurse practitioners—who prescribe and administer methadone must abide by any trainings or other requirements set by their province, territory, and licensing authority.¹² These training requirements vary based on jurisdiction. For example, in Newfoundland and Labrador, nurse practitioners must complete courses in OUD treatment and safe prescribing to provide methadone.¹³

Once they receive prescriptions, patients in Canada can fill them at a pharmacy, and all pharmacists can dispense methadone as long as they have a written order or prescription for the medication. This approach allows pharmacies to play a key role in the Canadian methadone delivery system.¹⁴ In 2020, community pharmacies dispensed nearly 14 million methadone doses for the treatment of OUD.¹⁵ And the number of methadone prescriptions dispensed has increased by approximately 1.9 million since 2015.¹⁶

Take-home methadone rules allow for individualized treatment

Canadian provincial guidelines vary, but, in general, they recommend patients get two to three initial months of supervised daily methadone doses at pharmacies or clinics. Ultimately, however, take-home methadone is available at the discretion of the prescribing provider.¹⁷ In British Columbia, for example, take-home schedules start with one per week and increase every month or two.¹⁸ The majority of patients deemed clinically stable— defined as receiving methadone doses for at least a month, attending all appointments and doses, showing an improved social and work life, and producing negative drug screens for at least 3 months—receive one take-home dose a week.¹⁹ This schedule progresses to additional take-home doses per week at the provider’s discretion, ultimately reaching five doses per week for most stable patients.²⁰

Changes in treatment as a result of COVID-19

During the COVID-19 pandemic, both federal and provincial bodies made recommendations to ensure continued access to methadone. At the request of the federal government, the Canadian Research Initiative in Substance Misuse issued national guidance recommending that telemedicine be considered to ensure continued access to care, and noting that methadone treatment can be initiated by telemedicine.²¹ This guidance stated that providers can start prescribing methadone via telemedicine if they determine that postponing medication would be risky for a patient and they meet certain conditions, such as obtaining the patient’s medical history and ensuring appropriate follow-up care.²² And in Ontario and British Columbia, among other provinces, guidance in response to the pandemic encouraged increased take-home medications.²³

As a result, there were small but statistically significant increases in the duration of methadone take-home doses in Ontario.²⁴ The percentage of people in Ontario who were given seven to 13 methadone take-home doses increased by 3.8%, and those that received 14 or more doses increased by 0.8%.²⁵ In addition, a 2021 qualitative study with participants from throughout the country found that of the 39% of participants who used methadone or buprenorphine during the pandemic, the majority (30%) identified positive changes to accessing these services.²⁶ The improvements included prescription renewals and refills via telemedicine, weekly dispensing instead of daily, and less stringent requirements to receive take-homes.²⁷

Treatment outcomes

Research from throughout Canada indicates that the country’s approach to making methadone treatment widely available is promising. In British Columbia, the number of people with OUD who had initiated opioid agonist treatment—medication treatment with either buprenorphine or methadone—increased each year from 2001 to 2017, sometimes by as much as 12% annually.²⁸

In addition, a 2018 study found marginal improvements in four OUD treatment indicators—connection to care, linkage to agonist treatment, remaining in treatment, and being clinically stable (e.g., no overdose reported)— during an 11-year time frame in Vancouver, British Columbia.²⁹ However, during the last two years of the study, these trends declined.³⁰ This falloff occurred after provincial regulatory changes to methadone treatment, which restricted pharmacy delivery of the medication and prohibited pharmacies from providing incentives such as money, food, and transportation that some patients needed to access care.³¹

Research has also found that, compared with the U.S., Canadian patients can access care more quickly. A 2021 study comparing timely access to methadone initiation in the U.S. and Canada during the COVID-19 pandemic found that the average first appointment wait time was greater among U.S. patients—3.5 to 4.1 days—versus Canadian patients, who had to wait only 1.9 days.³²

Patient perspectives

Studies examining patient perspectives identified several barriers that impact the effectiveness of methadone treatment.³³ They report internalized stigmatizing beliefs that this treatment is “substituting one drug for another”—a common misconception present in the U.S., as well—and that some health care delivery practices such as daily dosing, urine testing, and delayed treatment initiation can be burdensome.³⁴ Others noted that urine sample collection was degrading; similar sentiments regarding this practice have been identified in the U.S.³⁵

Despite these barriers, patients identified several positive aspects to their experiences with methadone treatment in Canada, noting that it helped them reduce drug use, provided a safe treatment option, and prolonged lives.³⁶ As one patient said:³⁷

Conclusion

As U.S. policymakers revisit opioid treatment program regulations, the Canadian methadone delivery system and these patient perspectives—both positive and negative—can be considered. And although some patients point to areas in need of improvement, the country’s overall approach to making methadone treatment more widely available by allowing patients to receive methadone in physician clinics and fill prescriptions at pharmacies has shown positive treatment outcomes and timely access to care. By adopting similar approaches, U.S. policymakers could likely improve equitable access for people with OUD in need of this lifesaving medication.

Endnotes

1. The Pew Charitable Trusts, “Medications for Opioid Use Disorder Improve Patient Outcomes” (2020), https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2020/12/medications-for-opioid-use-disorder-improve-patient-outcomes.
2. The Pew Charitable Trusts, “Improved Opioid Treatment Programs Would Expand Access to Quality Care” (2022), https://www.pewtrusts.org/-/media/assets/2022/03/improve-opioid-treatment-programs-to-expand-access.pdf.
3. World Health Organization, “Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence,” Geneva: World Health Organization, 2009, https://apps.who.int/iris/rest/bitstreams/52227/retrieve
4. Government of Canada, “Responding to Canada’s Opioid Overdose Crisis,” last modified July 5, 2022, https://www.canada.ca/en/health-canada/services/opioids/responding-canada-opioid-crisis.html.
5. M.E. Socías et al., “Trends in Engagement in the Cascade of Care for Opioid Use Disorder, Vancouver, Canada, 2006-2016,” Drug Alcohol Depend 189 (2018): 90-95.
6. Ibid.
7. Government of Canada, “Methadone Program,” last modified April 27, 2017, https://www.canada.ca/en/health-canada/services/health-concerns/controlled-substances-precursor-chemicals/exemptions/methadone-program.html; Government of Canada Regulations Amending the Narcotic Control Regulations and the New Classes of Practitioners Regulations (Diacetylmorphine (Heroin) and Methadone): Sor/2018-37 (2018), https://canadagazette.gc.ca/rp-pr/p2/2018/2018-03-21/html/sor-dors37-eng.html.
8. Ibid.
9. Canadian Research Initiative in Substance Misuse, “CRISM National Guideline for the Clinical Management of Opioid Use Disorder,” https://crism.ca/projects/opioid-guideline/; Canadian Research Initiative in Substance Misuse, “Telemedicine Support for Addiction Services” (2020), https://crism.ca/wp-content/uploads/2020/05/CRISM-National-Rapid-Guidance-Telemedicine-V1.pdf.
10. K.C. Priest et al., “Comparing Canadian and United States Opioid Agonist Therapy Policies,” International Journal of Drug Policy 74 (2019): 257-65, https://www.sciencedirect.com/science/article/pii/S0955395919300283.
11. Ibid.
12. Government of Canada, “Methadone Program”; Government of Canada Regulations Amending the Narcotic Control Regulations and the New Classes of Practitioners Regulations (Diacetylmorphine (Heroin) and Methadone): Sor/2018-37.
13. College of Registered Nurses of Newfoundland & Labrador, “Nurse Practitioner Authority to Prescribe Buprenorphine-Naloxone and/or Methadone for Opioid Use Disorder” (2021), https://crnnl.ca/resource/nurse-practitioner-authority-to-prescribe-buprenorphine-naloxone-suboxone-and-or-methadone-for-opioid-use-disorder/.
14. Government of Canada, “Methadone Program.”
15. IQVIA, “Prescription Opioid Trends in Canada” (2021), https://www.iqvia.com/-/media/iqvia/pdfs/canada/white-paper/prescriptionopioidtrendsincanada_report_en.pdf.
16. Ibid.
17. Canadian Research Initiative in Substance Misuse, “CRISM National Guideline for the Clinical Management of Opioid Use Disorder”; H. Jin et al., “Global Opioid Agonist Treatment: A Review of Clinical Practices by Country,” Addiction 115, no. 12 (2020): 2243-54, https://onlinelibrary.wiley.com/doi/abs/10.1111/add.15087.
18. College of Physicians and Surgeons of British Columbia, “Methadone Maintenance Program: Clinical Practice Guideline” (2015), http://www.bccdc.ca/resource-gallery/Documents/Statistics and Research/Publications/Epid/Other/02_CPSBC-Methadone_Maintenance_Program_Clinical _Practice_Guideline.pdf.
19. Ibid.
20. British Centre on Substance Use, “A Guideline for the Clinical Management of Opioid Use Disorder” (2017), https://www.bccsu.ca/wp-content/uploads/2017/06/BC-OUD-Guidelines_June2017.pdf
21. Canadian Research Initiative in Substance Misuse, “Telemedicine Support for Addiction Services.”
22. Ibid.
23. British Columbia Centre on Substance Use, “COVID-19: Information for Opioid Agonist Treatment Prescribers and Pharmacists” (2020), https://www.bccsu.ca/wp-content/uploads/2020/05/COVID-19-Bulletin-May-20-2020.pdf; The Centre for Addiction and Mental Health, “COVID-19 Opioid Agonist Treatment Guidance” (2021), https://www.camh.ca/-/media/files/covid-19-modifications-to-opioid-agonist-treatment-delivery-pdf.pdf?la=en&hash=261C3637119447097629A014996C3C422AD5DB05.
24. S.A. Kitchen et al., “Impact of the COVID-19 Pandemic on the Provision of Take-Home Doses of Opioid Agonist Therapy in Ontario, Canada: A Population-Based Time-Series Analysis,” International Journal of Drug Policy 103 (2022): 103644, https://www.sciencedirect.com/science/article/pii/S0955395922000640.
25. Ibid.
26. C. Russell et al., “Identifying the Impacts of the COVID-19 Pandemic on Service Access for People Who Use Drugs (PWUD): A National Qualitative Study,” Journal of Substance Abuse Treatment 129 (2021), https://doi.org/10.1016/j.jsat.2021.108374.
27. Ibid.
28. M. Piske et al., “The Cascade of Care for Opioid Use Disorder: A Retrospective Study in British Columbia, Canada,” Addiction 115, no. 8 (2020): 1482-93.
29. Socías et al., “Trends in Engagement in the Cascade of Care for Opioid Use Disorder.”
30. Ibid.
31. Ibid.; R. McNeil et al., “Negotiating Structural Vulnerability Following Regulatory Changes to a Provincial Methadone Program in Vancouver, Canada: A Qualitative Study,” Social Science & Medicine 133 (2015): 168-76, https://www.sciencedirect.com/science/article/pii/S0277953615002282.
32. P.J. Joudrey et al., “Methadone Access for Opioid Use Disorder During the COVID-19 Pandemic Within the United States and Canada,” JAMA Network Open 4, no. 7 (2021): e2118223-e23, https://doi.org/10.1001/jamanetworkopen.2021.18223.
33. C.P. Jeske and P. O’Byrne, “Perceptions and Experiences of Methadone Maintenance Treatment: A Qualitative Descriptive Research Study,” Journal of Addictions Nursing 30, no. 4 (2019), https://journals.lww.com/jan/Fulltext/2019/10000/Perceptions_and_Experiences_of_Methadone.5.aspx.
34. Ibid.
35. C. Strike and C. Rufo, “Embarrassing, Degrading, or Beneficial: Patient and Staff Perspectives on Urine Drug Testing in Methadone Maintenance Treatment,” Journal of Substance Use 15, no. 5 (2010): 303-12, https://www.tandfonline.com/doi/full/10.3109/14659890903431603?scroll=top&needAccess=true.
36. Jeske and O’Byrne, “Perceptions and Experiences of Methadone Maintenance Treatment: A Qualitative Descriptive Research Study.”
37. Ibid.